Posterior reversible encephalopathy syndrome associated with antibiotic therapy: a case report and systematic review

Abstract

Posterior reversible encephalopathy syndrome (PRES) is an acute neurological condition associated with different etiologies, including antibiotic therapy. To date, most data regarding antibiotic-related PRES are limited to case reports and small case series. Here, we report a novel case description and provide a systematic review of the clinico-radiological characteristics and prognosis of available cases of PRES associated with antibiotic therapy. We performed a systematic literature search in PubMed and Scopus from inception to 10 January 2024, following PRISMA guidelines and a predefined protocol. The database search yielded 12 subjects (including our case). We described the case of a 55-year-old female patient with PRES occurring one day after administration of metronidazole and showing elevated serum neurofilament light chain protein levels and favorable outcome. In our systematic review, antibiotic-associated PRES was more frequent in female patients (83.3%). Metronidazole and fluoroquinolones were the most reported antibiotics (33.3% each). Clinical and radiological features were comparable to those of PRES due to other causes. Regarding the prognosis, about one third of the cases were admitted to the intensive care unit, but almost all subjects (90.0%) had a complete or almost complete clinical and radiological recovery after prompt cessation of the causative drug. Antibiotic-associated PRES appears to share most of the characteristics of classic PRES. Given the overall good prognosis of the disease, it is important to promptly diagnose antibiotic-associated PRES and discontinue the causative drug.

Keywords: Adverse drug reactions; Antibiotics; Metronidazole; Neurofilament light chain; PRES; Posterior reversible encephalopathy syndrome.

Fig. 1

Clinical features and pathophysiological mechanisms of PRES associated with antibiotic and other drug administration. Disruption of the blood–brain barrier (BBB) with endothelial dysfunction (red box) leads to fluid leakage and vasogenic oedema with or without haemorrhage (blue box) in the central nervous system (CNS) interstitium. Drug intake (e.g., antineoplastic, immunomodulatory, and antimicrobial agents) might cause injury or inhibition of endothelial cell proliferation. Arterial hypertension is also a contributor in PRES pathophysiology. Involved risk factors are represented in red squares. Main clinical manifestations associated with PRES are summarized in the light blue box on the left part of the figure

Fig. 2

Imaging findings in our case of PRES after metronidazole administration. Native brain CT imaging showed A) right-sided occipital intracerebral haemorrhage with peripheral oedema (thin arrow), subdural bleeding (large arrow); left-sided grey-white matter junction oedema (*). MRI performed 2 days after clinical onset revealed bilateral occipital B) FLAIR (thin arrow and *) and C) ADC hyperintensities (thin arrow and *) indicating vasogenic edema. The relative right occipital hypointensity on the ADC map is related to the haemorrhage. D) Follow-up MRI after 2 months from clinical onset showed in the ADC map almost complete resolution of the vasogenic oedema and subtotal resorption of parenchymal haemorrhage (thin arrow and *). Abbrevations. ADC: apparent diffusion coefficient; CT: computed tomography; FLAIR: fluid-attenuated inversion recovery; MRI: magnetic resonance imaging; PRES: posterior reversible encephalopathy syndrome