Posterior Reversible Encephalopathy Syndrome Due to Malignant Hypercalcemia: Physiopathological Considerations

Abstract

The development of PRES in the setting of severe hypercalcemia is extremely rare. Hypercalcemia could lead to PRES in the absence of hypertension by various mechanisms, including vasospasm, endothelial dysfunction, and an inflammatory state. A high index of suspicion is needed in this setting because hypercalcemia can lead to neurological symptomatology, and prompt diagnosis is essential for adequate treatment.

Teaching Images in Headache: Concurrent Hypercalcemia‐Induced Reversible Cerebral Vasoconstriction Syndrome and Posterior Reversible Encephalopathy Syndrome

“…Hypercalcemia has been associated with numerous neurological symptoms including weakness, fatigue, confusion, and coma. Previous studies have reported the association of hypercalcemia with RCVS or PRES, but not both concurrently . RCVS and PRES share many clinico‐radiological features, which are typically reversible with prompt diagnosis and treatment.…”

Laboratory approaches for the diagnosis and assessment of hypercalcemia

“…Hypercalcemia has been described in infants with congenital lactase deficiency 81 ; the hypercalcemia may be due to an increase in calcium absorption in the ileum in the presence of non-hydrolyzed lactose, and it resolves rapidly after the institution of a lactose-free diet. Recently, hypercalcemia was reported to be associated with posterior reversible encephalopathy syndrome in a 38-year-old woman who presented with altered mental status 82 . Factors increasing bone resorption, including immobilization, Paget's disease and the administration of estrogen, can cause hypercalcemia 4,18,34 .…”

Posterior Reversible Encephalopathy Syndrome: A Case of Hypercalcemia

“…The number of associated conditions with PRES has increased although hypertension remains the most common, as well as renal disease, sepsis and immunosuppressive drug use. 8 Hypercalcemia is an extremely rare cause of PRES. 9 We report the case of PRES associated with a hypercalcemic crisis.…”

“…8,10,11 Neurologic manifestations are mainly cognitive and neuromuscular in nature and range from personality changes, to lack of concentration, memory impairment, and, in severe cases, lethargy and coma. 12 Other rarely reported neurologic manifestations include PRES.…”

“…12 Other rarely reported neurologic manifestations include PRES. 7,8 The most common cause of hypercalcemia is primary hyperparathyroidism either due to parathyroid adenoma, or due to malignancies, granulomatous diseases and iatrogenic causes. 12 Therefore, the diagnosis of PRES in the setting of hypercalcemia requires a high level of suspicion.…”