Obstructive ureteric calculus with superimposed infections causing reversible posterior leukoencephalopathy syndrome

Abstract

Rationale: Reversible posterior leukoencephalopathy syndrome (RPLS) is a clinicoradiological phenomenon first observed 2 decades ago. Reversibility is the hallmark of this rare clinical phenomenon once the triggering pathology is aptly and adequately treated. Tinnitus preceding bilateral hearing loss as a symptomatology of RPLS has not been reported in the literature. Furthermore, chronic obstructive ureteric calculus with superimposed infections as a cause of RPLS has not been reported in the literature. Patient concerns: A 57-year-old female was admitted at our facility because of 2 days history of hearing loss in both ears. She experienced tinnitus in both ears 2 weeks prior to the hearing loss. She is a known hypertensive. She has also undergone multiple surgical treatments for urinary calculi. Diagnosis: Computed tomography (CT) scan of the urinary system revealed a calculus at the right ureter. Magnetic resonance imaging (MRI) showed abnormal signals at both temporo-parieto-occipital (TPO) cortices, the subcortical area, as well as the left hippocampus which was consistent with the diagnosis of RPLS. Interventions: While on antibiotics for treatment of infections, the patient went into hypertensive encephalopathy and pneumonia was also established necessitating intensive care. Outcomes: We observed a resolution of the patient's temperature and hypertension when the right ureteric stone finally descended into the bladder. Also, we observed disappearance of the abnormal signals at both TPO cortices, the subcortical area, as well as the left hippocampus. Two years follow-up revealed no recurrence of her symptomatology. Lesions: Patients who present with hypertensive encephalopathy maybe more prone to developing RPLS. Renal insufficiency alone or hypertension alone may not be single predisposing entities to RPLS but rather multiple predisposing factors.

Hypertensive Encephalopathy: A Comprehensive Review

“…However, in circumstances of hypertension that exceed this autoregulation band, the compensatory increase in brain perfusion could inadvertently give rise to cerebral edema. [1][2][3][4] The brain has an impressive capability for maintaining a consistent blood flow even when systemic arterial pressure fluctuates. This principle operates within distinct limits, involving the pressure facilitating blood flow in the brain and the standard pressure within the arteries.…”

“…Clevidipine effectively lowers blood pressure without affecting cardiac filling pressures; however, it may cause reflex tachycardia. 1,12 Comparatively, studies have shown its effectiveness to be similar or superior to nitroglycerin, nitroprusside, and nicardipine in acutely hypertensive patients during and after cardiac surgery. 13 Some contraindications for clevidipine include severe aortic stenosis (due to an increased risk of severe hypotension), disordered lipid metabolism (as it is administered in a lipid-based emulsion), and known allergies to soy or eggs (as they are used in emulsion production).…”