Rare but not beyond care: a young female with altered mental status and seizures

Abstract

A 40-year-old Caucasian lady with focal crescentic glomerulonephritis (p-ANCA) demonstrated by kidney biopsy, was treated with intravenous pulse steroids followed by weekly outpatient rituximab infusions (375 mg/m2). Five days after the fourth and final rituximab infusion, she developed headaches, altered mental status and seizures. Upon transfer to our facility, magnetic resonance imaging of the brain revealed cortical white matter changes suggestive of possible progressive multifocal leukoencephalopathy (PML) or posterior reversible encephalopathy syndrome (PRES). She was aggressively treated with antihypertensives, anti-seizure medications, intravenous steroids, plasmapheresis and ventilatory support while awaiting cerebrospinal fluid analysis and polymerase chain reaction on John Cunningham virus DNA. She had a complete recovery and, at 1 year follow up, was found to be doing well. Awareness of potential complications of rituximab therapy, such as PRES or PML is critical in providing appropriate treatment.

A Young Patient with Microscopic Polyangiitis Requiring Hemodialysis with Complications of Repeated Episodes of Posterior Reversible Encephalopathy Syndrome Probably Due to Different Etiologies

“…Given the expression of CD20 in activated endothelial cells, rituximab may cause direct cell damage, endothelinmediated vasospasm and dysfunction, which may lead to PRES (28,29). PRES was reported to occur soon after the infusion of rituximab or five to six days after the last weekly infusion of rituximab on a uremic background with or without severe hypertension in patients with systemic lupus erythematosus or systemic vasculitis (28)(29)(30). Therefore, we suspected that her third PRES episode might have been due to rituximab infusion associated with hypertension rather than MPA.…”

Posterior Reversible Encephalopathy Syndrome Secondary to R-CHOP Chemotherapy Regimen

“…CD20 is expressed by all B lymphocytes but also by activated endothelial cells. Rituximab is therefore thought to cause direct endothelial toxicity and endothelin-induced vasospasm [6,7]. Post-chemotherapy PRES, therefore, involves a set of direct and indirect mechanisms that cause blood-brain barrier dysfunction [1].…”

Renal tissue engineering for regenerative medicine using polymers and hydrogels

“…9 Common causes of CKD include high blood pressure when continuous strain damages small vessels within the kidney 10 and diabetes, caused by metabolic changes due to hyperglycaemia. 11 There are several other causes, including autoimmune disease such as lupus nephritis, 12 a congenital condition such as polycystic kidney disease, a state where the kidney contains multiple fluid-filled cysts, 13 neuropathy such as diabetic and obstructive nephropathy, 14 and also urinary tract condition such as reflux nephropathy, a condition where kidney scarring happens due to urine backflow from the bladder towards the kidney, 15 can cause CKD. These conditions damage the kidney, initially affecting filtration efficiency and, eventually, its overall functionality, both mechanically and physiologically.…”