Case Report: A Fatal Case of Malignant Posterior Reversible Encephalopathy Syndrome in the Setting of Diabetic Ketoacidosis

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome that typically presents with headache, visual disturbances, seizures, and altered consciousness. Its hallmark radiological features involve subcortical white matter lesions on magnetic resonance imaging (MRI), predominantly in the parietal and occipital lobes. While generally reversible with favorable outcomes, a minority of cases may progress to malignant cerebral edema and herniation, resulting in death. We present an unusual case of a 47-year-old woman who developed malignant PRES associated with severe diabetic ketoacidosis (DKA). Despite aggressive medical and surgical treatments, the patient's condition worsened, indicating the potential for devastating outcomes in malignant PRES. This case adds to the limited body of literature that suggests the need for vigilance in monitoring patients with severe glycemic disturbances for neurological complications, such as PRES. It also highlights the importance of early recognition and aggressive management in improving neurological outcomes in malignant PRES. Further research is warranted to understand the underlying mechanisms better and identify optimal treatment strategies for this rare but potentially life-threatening condition.

Keywords: case report; diabetic ketoacidosis; dka; posterior reversible encephalopathy syndrome; pres.

Figure 1. Blood glucose trend

Blood glucose trend in the first seven days of hospitalization is represented by the solid line. The dotted line marks the upper (180 mg/dL) limit of the target blood glucose level.

Figure 2. Blood pressure trend in the first seven days of hospitalization

Figure 3. Magnetic resonance imaging and computed tomography of the brain

Fluid attenuated inversion recovery sequence demonstrating hyperintensities in subcortical white matter of bilateral occipital (A, white arrows), bilateral parietal (B, white arrows), and right frontal lobes (C, white arrows). A CT on the seventh day of hospitalization demonstrates bilateral mass effect on the midbrain with effacement of ambient cisterns in axial view (D, red arrows) and persistent hypodensity following subcortical white matter of bilateral occipital lobes (D, red asterisks).