IMAGES
IN THE
MEDICAL SCIENCES
Posterior Reversible Encephalopathy Syndrome Tayyab Rehman, MD* *Section of Pulmonary and Critical Care Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana (Email: [email protected]) The authors have no financial or other conflicts of interest to disclose.
FIGURE 1
A
FIGURE 2
CLINICAL PRESENTATION
58-year-old woman was admitted to the intensive care unit with altered mental status. Six months before presentation, the patient was diagnosed with breast cancer and underwent modified radical mastectomy followed by adjuvant chemotherapy. Two days before admission, the patient developed altered mental status and jerky limb movements after the administration of an antiemetic drug during a chemotherapy session. A computed tomography scan of the head revealed no significant abnormalities. Analysis of the cerebrospinal fluid showed normal levels for protein and glucose, normal pleocytosis and no evidence of infection or malignancy. The patient was admitted to the intensive care unit and provided supportive care. However, she remained persistently delirious with tremor, rigidity and hyperreflexia in all 4 extremities. This was associated with widely fluctuating blood pressures ranging from systolic 86 to 190 mm Hg and diastolic 48 to 116 mm Hg. On hospital day 9, the patient developed acute tonic rightward deviation of both her eyes. A repeat computed tomography scan of the head showed new hypodensities within the occipital and posterior parietal lobes bilaterally (Figure 1). A magnetic resonance imaging scan of the brain revealed vasogenic edema of the subcortical occipital lobe white matter bilaterally (Figure 2; T2-weighted, note rightward deviation of both eyeballs). These findings were consistent with a diagnosis of posterior reversible encephalopathy syndrome (PRES). Despite interventions to lower blood pressure and empiric antiseizure therapy, the patient’s mental status continued to deteriorate. One week later, the patient died.
244
In retrospect, the patient was discovered to be on sertraline, a selective serotonin reuptake inhibitor, before admission. It seems that the administration of the antiemetic drug—granisetron— precipitated the serotonin syndrome. Serotonin syndrome is characterized by the triad of altered mental status, dysautonomia and neuromuscular abnormalities in the setting of current or recent selective serotonin reuptake inhibitor use.1 Drugs of the 5-HT3 receptor antagonist family such as ondansetron and granisetron are known precipitants of the serotonin syndrome. Chemotherapy is a risk factor for PRES; however, selective serotonin reuptake inhibitors may further increase the risk through their effects on dysautonomia, cerebral vasoconstriction and impairment of cerebral autoregulation. An extensive literature search revealed less than 10 reported cases of PRES in association with selective serotonin reuptake inhibitor use2–4 and only 1 previous report of PRES in association with full-blown serotonin syndrome.2 REFERENCES 1. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005; 352:1112–20. 2. Chhakchhuak C, Anower M, Panda M. Reversible posterior leucoencephalopathy syndrome following duloxetine: a case report and review of literature. J Med Cases 2011;2:24–7. 3. Dacros A, Boukobza M, Porcher R, et al. The clinical and radiological spectrum of reversible cerebral vasoconstriction syndrome. A prospective series of 67 patients. Brain 2007;130:3091–101. 4. Irvin W, MacDonald G, Smith JK, et al. Dexamethasone-induced posterior reversible encephalopathy syndrome. J Clin Oncol 2007;25:2484–6.
The American Journal of the Medical Sciences
Volume 349, Number 3, March 2015
IN THE
MEDICAL SCIENCES
Posterior Reversible Encephalopathy Syndrome Tayyab Rehman, MD* *Section of Pulmonary and Critical Care Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana (Email: [email protected]) The authors have no financial or other conflicts of interest to disclose.
FIGURE 1
A
FIGURE 2
CLINICAL PRESENTATION
58-year-old woman was admitted to the intensive care unit with altered mental status. Six months before presentation, the patient was diagnosed with breast cancer and underwent modified radical mastectomy followed by adjuvant chemotherapy. Two days before admission, the patient developed altered mental status and jerky limb movements after the administration of an antiemetic drug during a chemotherapy session. A computed tomography scan of the head revealed no significant abnormalities. Analysis of the cerebrospinal fluid showed normal levels for protein and glucose, normal pleocytosis and no evidence of infection or malignancy. The patient was admitted to the intensive care unit and provided supportive care. However, she remained persistently delirious with tremor, rigidity and hyperreflexia in all 4 extremities. This was associated with widely fluctuating blood pressures ranging from systolic 86 to 190 mm Hg and diastolic 48 to 116 mm Hg. On hospital day 9, the patient developed acute tonic rightward deviation of both her eyes. A repeat computed tomography scan of the head showed new hypodensities within the occipital and posterior parietal lobes bilaterally (Figure 1). A magnetic resonance imaging scan of the brain revealed vasogenic edema of the subcortical occipital lobe white matter bilaterally (Figure 2; T2-weighted, note rightward deviation of both eyeballs). These findings were consistent with a diagnosis of posterior reversible encephalopathy syndrome (PRES). Despite interventions to lower blood pressure and empiric antiseizure therapy, the patient’s mental status continued to deteriorate. One week later, the patient died.
244
In retrospect, the patient was discovered to be on sertraline, a selective serotonin reuptake inhibitor, before admission. It seems that the administration of the antiemetic drug—granisetron— precipitated the serotonin syndrome. Serotonin syndrome is characterized by the triad of altered mental status, dysautonomia and neuromuscular abnormalities in the setting of current or recent selective serotonin reuptake inhibitor use.1 Drugs of the 5-HT3 receptor antagonist family such as ondansetron and granisetron are known precipitants of the serotonin syndrome. Chemotherapy is a risk factor for PRES; however, selective serotonin reuptake inhibitors may further increase the risk through their effects on dysautonomia, cerebral vasoconstriction and impairment of cerebral autoregulation. An extensive literature search revealed less than 10 reported cases of PRES in association with selective serotonin reuptake inhibitor use2–4 and only 1 previous report of PRES in association with full-blown serotonin syndrome.2 REFERENCES 1. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med 2005; 352:1112–20. 2. Chhakchhuak C, Anower M, Panda M. Reversible posterior leucoencephalopathy syndrome following duloxetine: a case report and review of literature. J Med Cases 2011;2:24–7. 3. Dacros A, Boukobza M, Porcher R, et al. The clinical and radiological spectrum of reversible cerebral vasoconstriction syndrome. A prospective series of 67 patients. Brain 2007;130:3091–101. 4. Irvin W, MacDonald G, Smith JK, et al. Dexamethasone-induced posterior reversible encephalopathy syndrome. J Clin Oncol 2007;25:2484–6.
The American Journal of the Medical Sciences
Volume 349, Number 3, March 2015
