Cocaine-Induced Posterior Reversible Encephalopathy Syndrome (PRES): A Case Report and Review of the Literature

Abstract

Background: Posterior Reversible Encephalopathy Syndrome (PRES) is a clinical-radiological phenomenon that occurs due to a disruption in the autoregulation of the cerebral blood flow resulting in vasogenic edema. It is seen most often in settings of acute hypertension and is often associated with eclampsia. Symptoms that PRES patients commonly present with include seizures, visual disturbances, headache, and altered mental status. Case: We present a patient and review select cases cited in the literature that cocaine, a common drug of abuse, can precipitate hypertension with PRES. Our patient initially presented with severe headache, acute renal failure, hypertension, profound somnolence, and a widespread vasogenic edema after relapsing and using cocaine. Within 24 hours and with control of her blood pressure, her symptoms resolved and she was alert, cognitively intact and free from any identifiable residual effects. Conclusion: We suggest that this rapid sequence of clinical and neuroimaging abnormalities following cocaine ingestion may not be a rare phenomenon. As has been previously described, the magnitude of PRES related vasogenic edema is not well correlated with either symptom severity or ultimate clinical outcome.

Posterior Reversible Encephalopathy Syndrome in Clinical Toxicology: A Systematic Review of Published Case Reports

“…The neuroimaging findings, including anatomical pattern, diffusion-weighted imaging (DWI), apparent diffusion coefficient (ADC), edema type, symmetry, and arterial characteristics, are summarized in Supplementary Table 3. Five patients (19,24,26,34,44) had normal initial brain CT (5/9, 56%) (19,20,24,26,34,42,44,48,50). All patients exhibited cortical and/or subcortical edema, characterized by hyperintensities in T2-weighted and/or T2 fluid-attenuated inversion recovery (FLAIR) imaging, which was consistent with PRES diagnosis in MRI.…”

“…This may partially explain the difference in prevalence, especially since the whole brain MRI was not available for neuroradiological analysis. The atypical distribution involving the thalamus (18,19,21,34), basal ganglia (18,19,46), midbrain (18,19), and corpus callosum (39) was less commonly reported, as described in the literature. As with other PRES etiologies, atypical imaging appearances including hemorrhage, contrast enhancement, and restricted diffusion on MRI were reported in similar proportions (58).…”

“…The initial clinical presentation was alertness disorders in 64% of patients (13)(14)(15). Visual disturbances were reported in 55% of patients ( (19,20,35), visual hallucination (21,23,26,27), and cortical blindness (15,16,24,29,34,37). Four patients had concurrent acute kidney failure with PRES (13,19,44,48).…”

“…We collected six reports of illicit drug-induced PRES, involving cocaine (18,19), amphetamine (52), mephedrone (50), kratom (20), and lysergic acid amide (21). Acute high blood pressure was reported in all patients (18-21, 50, 52).…”

“…Acute high blood pressure was reported in all patients (18-21, 50, 52). Patients had several risk factors for PRES such as chronic hypertension (18,19), chronic kidney disease (18,19), alcohol abuse (21,50), and HIV infection (18).…”