Posterior Reversible Encephalopathy Syndrome in a Patient with Newly Diagnosed HIV Infection and End Stage Renal Disease

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome in which patients present with an acute or subacute clinical presentation of seizures, visual disturbances, headache, and altered mental status. The pathophysiology of PRES may be explained by endothelial dysfunction that leads to transudation of fluids and protein, resulting in vasogenic cerebral edema. PRES is typically associated with many conditions such as hypertension, uremia, immunosuppressive drugs, and sepsis. This is a case report of a 39-year-old woman with untreated HIV infection and end-stage renal disease (ESRD) who developed PRES with a normal blood pressure and no other known causes of PRES. Untreated HIV is associated with known endothelial dysfunction and we believe that this, in combination with her untreated end-stage renal disease, contributed to her unique presentation of PRES. Although uncommon in HIV-infected patients and challenging to diagnose, prompt recognition of PRES is critical to provide appropriate care and ensure reversibility of the vasogenic edema seen in PRES.

An atypical subacute presentation of posterior reversible encephalopathy syndrome

“…HIV infection has been implicated as the etiological factor in many published cases of PRES [8,9,11,13]. HIV virus has been shown to induce endothelial cell apoptosis, tight junction disruption, oxidative stress, and the expression of pro-inflammatory cytokines and adhesion molecules which stimulate endothelial cell inflammation, all of which culminates in BBB dysfunction [11,16,17].…”

“…HIV virus has been shown to induce endothelial cell apoptosis, tight junction disruption, oxidative stress, and the expression of pro-inflammatory cytokines and adhesion molecules which stimulate endothelial cell inflammation, all of which culminates in BBB dysfunction [11,16,17]. Most reported cases of PRES occurred in patients with low CD4 counts (range 16–284 cells/ μ l) [9,13,18–21], however, HIV-induced pathology has not been shown to be related to viral load [22]. …”

“…Both volume overload resulting from irregular hemodialysis and the fluid shifts that occur during hemodialysis can lead to endothelial dysfunction in patients with ESRD and have been implicated as precipitants of PRES in patients with ESRD [1,9,13]. …”

Posterior Reversible Encephalopathy Syndrome in a Patient with Severe Uremia without Hypertension

“…In their case, PRES-related symptoms resolved after the initiation of dialysis, similar to our case. In addition, Kurukumbi et al described a normotensive case of PRES with untreated HIV infection and end-stage renal disease (19). HIV infection and end-stage renal disease cause endothelial dysfunction.…”

“…HIV infection and end-stage renal disease cause endothelial dysfunction. Kurukumbi et al speculated that endothelial dysfunction associated with untreated HIV infection and end-stage renal disease induced PRES without hypertension (19).…”