Case Report: Posterior Reversible Leukoencephalopathy Syndrome (PRES) as a Biologically Predictable Neurological Association in Severe COVID-19. First Reported Case From Australia and Review of Internationally Published Cases

Abstract

Reports of different types of neurological manifestations of COVID-19 are rapidly increasing, including changes of posterior reversible leukoencephalopathy syndrome (PRES). Here we describe the first reported case of COVID-19 and PRES in Australia diagnosed on basis of MRI brain imaging and confirmed clinically by presence of confusion, delirium, headaches, also associated with hypertension and blood pressure variability and stable long-term kidney problems. He made full recovery as his blood pressure was controlled and clinical status was supported with appropriate supportive therapy. Although traditionally a rare condition, PRES is likely to be more common among patients with COVID-19 pathobiology there is Renin downregulation of ACE2 receptors, involvement of Renin-Angiotensin-Aldosterone system, endotheliitis, cytokine storm, and hyper-immune response. Thus we advocate clinical suspicion and early brain imaging with MRI brain among vulnerable patients with known co-morbidities, and diagnosed with COVID-19 given that hypertension and blood pressure variability are often exacerbated by acute SARS-CoV-2 immune reactions. Such acute hypertensive encephalopathy was able to be reversed with timely supportive therapy ensuring re-hydration and re-establishment of blood pressure control.

Brain MRI findings in COVID-19 patients with PRES: A systematic review

“…3rd MRI-progression of white signal abnormality. NR Present Discharged P29/M/55 Wijeratne T et al 42 Hypertensive Absent Present Absent NR NR Bilateral parietal-occipital T2 FLAIR hyperintensities. Diffuse petechial hemorrhages in basal ganglia and deep white matter.…”

Persistent visual dysfunction following posterior reversible encephalopathy syndrome due to COVID‐19: Case series and literature review

“…Database search recovered 37 unique articles describing PRES and COVID‐19, of which five were excluded after abstract review. The remaining 32 articles underwent full text review; 22 articles met all inclusion criteria and contained detailed clinical information on 32 individuals with PRES and COVID‐19 [6–27]. All cases reported MRI findings consistent with a diagnosis of PRES (Table 1).…”

“…The majority of cases of PRES occurred in the setting of critical COVID‐19 illness requiring mechanical ventilation or severe COVID‐19 requiring other forms of respiratory support (Figure 4a) [5]. Seven cases (20%) reported development of PRES with only mild or asymptomatic COVID‐19 (Figure 4a) [5,10,12–14,16,26,27]. Of these, three individuals were older than 65 years, with medical risk factors for COVID‐19 [1,10,12,16], and two were peripartum (Table 1) [13,26].…”

“…. Seven cases (20%) reported development of PRES with only mild or asymptomatic COVID-19 (Figure4a)[5,10,[12][13][14]16,26,27].Of these, three individuals were older than 65 years, with medical risk factors for COVID-19[1,10,12,16], and two were peripartumF I G U R E 2 Brain magnetic resonance imaging (MRI), Case 2. (a, b) T2-weighted imaging sequence with fluid attenuation and inversion recovery (T2/FLAIR) for MRI of the brain of Case 2 on day of seizure (hospital Day 14) showed extensive bilateral hyperintensities in the white matter of the (a) occipital lobes and (b) frontoparietal lobes.…”

A 33-year-old in puerperium with posterior reversible encephalopathy syndrome in course of severe COVID-19

“…The described case suggests that PRES may be a rare neurological presentation in the course of severe COVID-19 [1][2].…”