Posterior Reversible Encephalopathy Syndrome Presenting Atypically as a Non-Convulsive Seizure

Abstract

Patient: Female, 59-year-old Final Diagnosis: Posterior reversible encephalopathy syndrome (PRES) Symptoms: Altered mental status Medication:— Clinical Procedure: — Specialty: Cardiology • Critical Care Medicine • General and Internal Medicine • Nephrology • Neurology Objective: Unusual clinical course Background: Posterior reversible encephalopathy syndrome (PRES), also known as reversible posterior leukoencephalopathy, is a neurotoxic state with multiple etiologies characterized by altered mental state, headaches, visual abnormalities, and seizures. This clinico-radiological syndrome is rare, and a high index of suspicion is needed to diagnose, provide adequate treatment, and prevent irreversible neurological sequelae. Case Report: We present a case of a woman with end-stage renal disease (ESRD) who presented with acute confusion and non-convulsive seizures and was later diagnosed with PRES. In this case, altered mental status was initially thought to be secondary to uremic encephalopathy. A diagnosis of PRES was subsequently made after she had several sessions of HD without significant improvement in her mental state, prompting magnetic resonant imaging (MRI) for further evaluation. Specific risk factors for PRES, including blood pressure fluctuations, were targeted and she made significant clinical recovery but had residual functional impairment. Conclusions: This case underscores the need for a high index of suspicion, especially in cases with atypical presentation, as delayed diagnosis can lead to suboptimal outcomes.

Posterior Reversible Encephalopathy Syndrome: Literature Review and Clinical Challenges

“…PRES early warning scoring (PEWS) incorporates several clinical parameters, including hypertension, visual symptoms, seizure, consciousness disturbance, and slow electroencephalogram (EEG) waves or epileptic discharges. PRES is diagnosed when 10 or more PEWS points are found [12].…”

“…EEG can be done to exclude non-convulsive status epilepticus. However, it lacks sensitivity and specificity as no characteristic EEG waves exist for PRES [12,13].…”

“…Early and timely neuroimaging makes the diagnosis of PRES easier for physicians. However, neuroimaging misinterpretation can lead to the suspicion of other diseases, such as cerebral infarction, paraneoplastic demyelinating disorder, or acute disseminated encephalomyelitis [12].…”