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Case Reports
. 2023 Sep 29;24(1):286.
doi: 10.1186/s12882-023-03319-7.

Posterior reversible encephalopathy syndrome (PRES) associated with SARS-CoV-2 infection in a patient under maintenance haemodialysis: a case report

Yuki Shimamoto  1 , Hirohito Sasaki  2 , Kenji Kasuno  3 , Yuki Watanabe  1 , Sayumi Sakashita  1 , Sho Nishikawa  1 , Kazuhisa Nishimori  1 , Sayu Morita  1 , Yudai Nishikawa  1 , Mamiko Kobayashi  1 , Sachiko Fukushima  1 , Soichi Enomoto  2 , Naoki Takahashi  1 , Tadanori Hamano  2 , Ippei Sakamaki  4 , Hiromichi Iwasaki  5 , Masayuki Iwano  1
Affiliations
Case Reports

Posterior reversible encephalopathy syndrome (PRES) associated with SARS-CoV-2 infection in a patient under maintenance haemodialysis: a case report

Yuki Shimamoto et al. BMC Nephrol. .

Abstract

Background: Endothelial dysfunction is common in patients undergoing chronic haemodialysis, and is a major cause of posterior reversible encephalopathy syndrome (PRES). Recently, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been shown to cause endothelial dysfunction by infecting vascular endothelial cells. Several cases of neurological complications in patients without kidney dysfunction, and only a few cases in patients with chronic kidney disease, have been reported in the literature. However, no previous report has yet described PRES associated with SARS-CoV-2 infection among patients undergoing maintenance dialysis.

Case presentation: A 54-year-old woman undergoing maintenance haemodialysis was admitted to our hospital for status epilepticus. She had developed end-stage kidney disease (ESKD) secondary to diabetic nephropathy. Seven days prior to admission, she had developed fever and was diagnosed with COVID-19. Subsequently her blood pressure increased from 160/90 mmHg to 190/100 mmHg. On admission, she presented with severe hypertension (> 220/150 mmHg), unconsciousness, and epilepticus. CT tomography revealed no signs of brain haemorrhage. Cranio-spinal fluid (CSF) examination revealed no signs of encephalitis, and CSF polymerase chain reaction (PCR) for SARS-CoV-2 was negative. MRI findings revealed focal T2/FLAIR hyperintensity in the bilateral parietooccipital regions, leading to the diagnosis of PRES. Deep sedation and strict blood pressure control resulted in a rapid improvement of her symptoms, and she was discharged without sequelae.

Conclusions: We report the first case of PRES associated with SARS-CoV-2 infection in a patient undergoing maintenance haemodialysis. Patients undergoing maintenance haemodialysis are at high risk of PRES because of several risk factors. SARS-CoV-2 infection causes direct invasion of endothelial cells by binding to angiotensin-converting enzyme 2 (ACE2), initiating cytokine release, and hypercoagulation, leading to vascular endothelial cell injury and increased vascular leakage. In the present case, SARS-CoV-2 infection possibly be associated with the development of PRES.

Keywords: End-stage kidney disease; Haemodialysis; Intravascular endothelial cell injury; Posterior reversible encephalopathy syndrome; Status epilepticus.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
MRI findings on admission Bilateral multifocal hyperintensities in the cortical and subcortical areas of the parietal lobe (a) and cerebellum (c) could be seen on FLAIR. ADC mapping hyperintensities are present in the same region as FLAIR (b, d), suggesting that these changes were vasogenic oedema. High magnification of cerebellar abnormalities in FLAIR and ADC mapping (e, f)
Fig. 2
Fig. 2
MRI and MRA findings on admission DWI hyperintensities are present in the left occipital lobe (a), and the left MCA and left PCA are dilated (b). ASL/CBF revealed increased blood flow in the same region (c), suggesting that the left parietal lobe was the focus of epilepsy
Fig. 3
Fig. 3
Resolution of abnormal findings on MRI on day 15 Multifocal hyperintensities of the parietal lobe (a) and cerebellum (b) are completely resolved
See this image and copyright information in PMC

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