LETTER TO THE EDITOR

Posterior Reversible She was a case of hypertensive encephalopathy. On the

basis of given clinical evaluation, encephalitis,
Encephalopathy Syndrome glomerulonephritis, and renal artery stenosis were
considered as possible underlying causes leading to
Secondary to Acute Post- hypertension.

Streptococcal Glomerulonephritis
Complete Blood Counts (CBC) showed Total Leukocyte
Counts (TLC) 12,000/mm 3 with 70% neutrophils,

in a 12-year-old Girl
hemoglobin 13 g/dl, erythrocyte sedimentation rate
(ESR) 40 mm/1st hour, and C-reactive protein 48 mg/dl.
Blood sugar, electrolytes, liver function tests, renal
parameters and cerebrospual fluid (CSF) examination
Sir, were completely normal.
Posterior Reversible Encephalopathy Syndrome (PRES) Urine microscopy showed protein ++, blood +++, red
is a syndrome characterized by headache, confusion, blood cells (RBCs) 60-70/HPF, white blood cells (WBCs)
seizures and visual loss.1 The major abnormality is 3-4/HPF. Anti-streptolysin O (ASO) titer was positive
cerebral vasogenic edema. Its pathogenesis is still under (400 IU/ml) with low complement C3 levels, 70 mg/dl. On
debate.2 imaging procedures, she had normal ultrasound
It is a reversible condition which usually affects the abdomen with normal Doppler renal scan.
occipital lobes, but structures of the posterior fossa can We started initial treatment by maintaining her airway,
also be involved.3 breathing, circulation; and giving her injectable
antibiotics, diuretics, antihypertensives and analgesics.
PRES has been reported in patients of 4 to 90 years of
age with mean age ranging from 39 to 47 years.4 Two days after hospitalization, patient developed gross
hematuria and sudden loss of vision. MRI brain showed
Fugate et al. found causes of PRES as hypertension
abnormal symmetrical MR signals return from bilateral
(61%), autoimmune disease (45%), cytotoxic drugs (19%),
frontal, posterior temporal and occipital regions, which
sepsis (7%), preeclampsia (6%), and multiple organ
dysfunctions (1%).5
Herein, we present a case of PRES secondary to renal
involvement in a 12-year-old girl.
A 12-year-old girl presented to emergency department
with complaints of abdominal pain, headache and
vomiting for 2 days, fits and altered level of
consciousness for 1 day. Abdominal pain was sudden,
severe and involved flank regions. Vomiting was non-
projectile, frequent, containing no blood. Headache was
severe, more in frontal region and associated with
blurring of vision. There were 2-3 episodes of fits, each
lasting for 3-4 seconds, associated with impaired
consciousness. There was burning micturition and Figure 1: Abnormal symmetrical hyperintense signals return from bilateral
frontal, posterior temporal and occipital regions, suggestive of PRES.
decreased urine output. She had no other complaints.
She was vitally stable apart from her raised blood
pressure (BP), i.e. 150/110 mmHg. She was semi-
conscious with anthropometric measurements at 25th
centiles for her age. There was no pallor, body rash,
lymphadenopathy, and oral ulcers. Her Glassgow coma
scale (GCS) was 13/15 with normal muscle tone and
power. She had brisk reflexes with negative signs of
meningeal irritation and down-going plantars. Her pupils
were bilaterally equal and reactive while fundoscopy
revealed bilateral papilledema. Abdomen was tender
in lumbar regions. Rest of the examination was Figure 2: MRI brain on 6 weeks follow-up showing complete resolution of
unremarkable. abnormal hyperintense signals.

80 Journal of the College of Physicians and Surgeons Pakistan 2018, Vol. 28 (1): 80-81
Letter to the editor
were iso on T1w, high on T2w; and FLAIR images showed
no diffusion restriction (Figure 1).
Final diagnosis was PRES secondary to acute post-
streptococcal glomerulonephritis.
We continued same treatment. Her BP was controlled
and vision restored after 4 days. She was discharged on
antihypertensive medications and advised follow-up. Six
weeks after her initial scan, her repeat MR scan showed
complete resolution (Figure 2).
Hypertension is an important trigger for PRES. It is of
utmost importance to identify the characteristic
radiological findings on MRI. PRES should always be
kept as a likely possibility in children who present with
encephalopathy and seizures in the background of
raised BP or kidney disease; because delay in diagnosis
and treatment may cause permanent neurological
deficit.
REFERENCES
1. Wikipedia contributors. Posterior reversible encephalopathy
syndrome. From: https://en.wikipedia.org/w/index.php?title=
Posterior_reversible_encephalopathy_syndrome&oldid=7835
19743. Accessed: June 2017.
Journal of the College of Physicians and Surgeons Pakistan 2018, Vol. 28 (1): 80-81
2. Bartynski WS. Posterior reversible encephalopathy syndrome,
part 2: controversies surrounding pathophysiology of
vasogenic edema. Am J Neuroradiol 2008; 29:1043-9.
3. Grossbach AJ, Abel TJ, Hodis B. Hypertensive posterior
reversible encephalopathy syndrome causing posterior
fossa edema and hydrocephalus. J Clin Neurosci 2014; 21:
207-11.
4. Legriel S, Pico F, Azoulay E. Understanding posterior
reversible encephalopathy syndrome. In: Vincent JL, Eds.
Annual update in intensive care and emergency medicine
2011. Springer Science+Business Media LLC, 2011; p. 631-53.
5. Fugate JE, Claassen DO, Cloft HJ. Posterior reversible
encephalopathy syndrome: Associated clinical and radiologic
findings. Mayo Clin Proc 2010; 85:427-32.
Javaria Rasheed, Rushan Hassan and Fauzia Zafar
Department of Pediatric Medicine Unit-1, Nishtar Hospital,
Multan.
Correspondence: Dr. Javaria Rasheed, Senior Registrar
Pediatric Medicine Department Unit-1, Nishtar Hospital,
Multan.
E-mail: jiyojiya@yahoo.com
Received: August 03, 2017; Accepted: October 23, 2017.
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