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Reversible Posterior Leukoencephalopathy Syndrome (RPLS) in a Young Male With Uncontrolled Hypertension FREE TO VIEW

Praveen Jinnur, MD; Viswanath Vasudevan, MD; Vijay Vanam, MD; Shanthakumari Jinnur, MD; Qammar Abbas, MD; Farhad Arjomand, MD; Mahmoud Dakhel, MD
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The Brooklyn Hospital Center, Brooklyn, NY

Chest. 2013;144(4_MeetingAbstracts):288A. doi:10.1378/chest.1704604
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SESSION TITLE: Critical Care Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: RPLS is characterized by headache, confusion, seizures and visual loss. Important causes attributed include uncontrolled hypertension, renal failure, eclampsia and cytotoxic drug therapy. We present here a case of RPLS in a young male admitted with acute renal failure and uncontrolled hypertension.

CASE PRESENTATION: 28 year-old previously healthy male was admitted to ICU with cardiogenic shock, acute liver failure and acute renal failure following a party in which he consumed alcohol, marijuana and MDMA. He was in acute respiratory failure, acute renal failure and acute liver failure. Patient received supportive care in ICU following which his liver function recovered. He was noted to develop hypertension during this admission likely secondary to poor renal function. On day 10 of admission, he complained of blurring of vision and headache without any focal weakness. His BP was 200/100 and developed a brief episode of tonic clonic seizure which lasted 2 minutes. CT scan of head showed foci of hypodensity in cerebellum and midbrain. MRI of brain showed increased FLAIR / T2 signal intensity in both cerebellum, gyri of occipital lobes bilaterally and posterior gyri of frontal lobes without any mass effect. Blood pressure was controlled adequately and visual symptoms improved over 24 hours.

DISCUSSION: The pathogenesis of RPLS has been attributed to a temporary failure of cerebral autoregulation leading to hyperperfusion. Parietal and occipital lobes are preferentially involved. CT scan shows areas of low attenuation of white matter which are relatively symmetric and bilateral. The lesions appear hypointense on T1 and hyperintense on T2-weighted MRI studies. MRI with fast fluid-attenuated inversion recovery (FLAIR) images is more sensitive. Brainstem, cerebellum, basal ganglia, and frontal lobes can also be affected and asymmetric involvement is not unusual. A prompt reduction of BP leads to the rapid reversal. Delay in controlling blood pressure can result in permanent neurologic damage secondary to ensuing cerebral infarction, hemorrhages, and even death.

CONCLUSIONS: : It is important to distinguish between a brain infarct and RPLS early, because, in the case of brain infarction mild to moderate hypertension should not be treated. However in patients with RPLS, blood pressure control is essential to reverse the pathologic process before permanent damage occurs. MRI with FLAIR imaging if available should be used early in suspected cases. This would lead to prompt diagnosis and early initiation of appropriate therapy.

Reference #1: Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, Pessin M, Lamy C, Mas J, Caplan L (1996). "A reversible posterior leukoencephalopathy syndrome.". N Engl J Med 334 (8): 494-500

DISCLOSURE: The following authors have nothing to disclose: Praveen Jinnur, Viswanath Vasudevan, Vijay Vanam, Shanthakumari Jinnur, Qammar Abbas, Farhad Arjomand, Mahmoud Dakhel

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