Posterior reversible encephalopathy syndrome (PRES) associated with COVID-19

Abstract

The novel human coronavirus disease (COVID-19) has been associated with vascular and thrombotic complications, some of which may result from endothelial dysfunction, including the posterior reversible encephalopathy syndrome (PRES). We report a case series of 8 patients with COVID-19 and PRES diagnosed at two academic medical centers between March and July of 2020. The clinical, laboratory and radiographic data, treatment, and short-term outcomes were retrospectively analyzed. The mean age was 57.9 ± 12 years, and 50% were women. Four patients had previous vascular comorbidities. All the patients suffered from severe pneumonia, requiring intensive care unit admission. Five patients were not hypertensive at presentation (all SBP < 127 mmHg). Neurologic symptoms included seizures in 7 patients; impaired consciousness in 5 patients; focal neurological signs in 3 patients; and visual disturbances in 1 patient. All patients underwent brain magnetic resonance imaging which indicated asymmetric T2 prolongation or diffusion changes (50%), extensive fronto-parieto-occipital involvement (25%), vascular irregularities (12.5%) and intracranial hemorrhage (25%). Four patients were treated with tocilizumab. Three patients were discharged without neurologic disability, 2 patients had persistent focal neurologic deficits and 2 expired. One patient's prognosis remains guarded. Together, these data support the relationship between PRES and endothelial dysfunction associated with severe COVID-19. In patients with severe COVID-19, PRES can be triggered by uncontrolled hypertension, or occur independently in the setting of systemic illness and certain medications. Like other infectious processes, critically ill patients with COVID-19 may be at greater risk of PRES because of impaired vasoreactivity or the use of novel agents like Tocilizumab.

The association of posterior reversible encephalopathy syndrome with COVID-19: A systematic review

“…The remaining 34 articles, including case reports, case series, letters to the editor, pictorial essays etc. reporting cases of PRES in COVID-19 were finally shortlisted after rigorous screening [ [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] , [45] , [46] , [47] , [48] , [49] ]. Since a total of 31 patients were described in the nine case series, individual data of 56 patients is described in our systematic review in the form of two tables [ Table 1 and Table 2 ].…”

A broad spectrum of posterior reversible encephalopathy syndrome - a case series with clinical and paraclinical characterisation, and histopathological findings

“…In our study, PRES occurred in a wide range of disorders and predisposing conditions ranging from hypertension, eclampsia to stem cell transplantation, exposure to various immunosuppressants and cytostatic drugs as well as coproporphyria and serotonin syndrome. During the recent coronavirus disease 2019 (COVID-19) pandemic, COVID-19 infection has been identified as a further co-morbid condition of PRES [ 12 – 14 ]. In one case, PRES showed a recurrence after a first episode 5 years before, suggesting a certain predisposition and the risk of recurrence if trigger factors are not eliminated, in this case hypertension.…”

Posterior Reversible Encephalopathy Syndrome: A Rare Complication in COVID-19

“…Recent studies suggest that the PRES is increasingly being reported in COVID-19. For instance, Lallana et al [ 6 ] reported eight cases of PRES in patients with COVID-19 requiring intensive care admission and mechanical ventilation. It was noted that half of those patients received immunomodulatory therapy suggesting its role in the pathogenesis of PRES in COVID-19.…”