Recurrent Posterior Reversible Encephalopathy Syndrome Potentially Related to AIDS and End-Stage Renal Disease: A Case Report and Review of the Literature

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome that is characterized by clinical features including headache, altered mental status, cortical blindness, seizures, and other focal neurological signs as well as subcortical edema without infarction on neuroimaging. Under the umbrella of hypertensive encephalopathy, PRES is defined by reversible cerebral edema due to dysfunction of the cerebrovascular blood-brain barrier unit. The pathophysiology of PRES is thought to result from abnormalities in the transmembrane flow of intravascular fluid and proteins caused by two phenomena: one, cerebral autoregulatory failure and two, loss of integrity of the blood-brain barrier. PRES is not a common disease in patients with human immunodeficiency virus (HIV) and AIDS with only three previously reported cases. Both the HIV and end-stage renal disease appear to further compromise the blood brain barrier. Although uncommon, PRES recurrence has been described. To the best of our knowledge, this is the first report demonstrating recurrent PRES in a HIV patient on hemodialysis for end-stage renal disease.

An atypical subacute presentation of posterior reversible encephalopathy syndrome

“…While the patterns of distribution of such signal hyper intensities are now known to vary, historically PRES was thought to produce bilateral and symmetric lesions in the posterior temporal, parietal, and occipital regions of the brain [2,6]. The posterior circulation was believed to be preferentially affected due to its relatively poorer sympathetic innervation [13]. Cohort studies [6,12] have described four different radiological patterns of PRES and reported that this archetypal pattern, referred to as ‘the dominant parietal-occipital pattern’, occurred in only 22% in their studied cohort of 136 cases.…”

“…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]. …”

PRES with First Time Seizure in a Newly Diagnosed HIV Patient: A Case Report

“…For instance, antiretroviral therapy has been observed to cause PRES [3,4,5]. Alternatively, HIV patients receiving non-HIV-related treatment that results in additional immunosuppression, have also been reported [6,7,8,9]. PRES due to the actual immunosuppression of HIV, without the administration of HIV therapy is much less well-documented [1, 10, and 11].…”