Posterior Reversible Encephalopathy Syndrome in COVID-19 Disease: a Case-Report
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COVID-19
Posterior Reversible Encephalopathy Syndrome in COVID-19 Disease: a Case-Report Laura Llansó 1
&
Xabi Urra 1,2
Accepted: 20 August 2020 # Springer Nature Switzerland AG 2020
Abstract Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome that can include headache, altered consciousness, visual disturbances, and seizures, usually related to autoregulatory cerebral failure and hypertension. The neuroimaging is essential to diagnosis, showing white matter vasogenic edema in posterior areas. We present a case of a 66-year-old woman with severe pneumonia by SARS-CoV-2 who developed a posterior reversible encephalopathy syndrome with a typical clinical and radiological presentation, after being treated with anti-interleukin treatment (anakinra and tocilizumab) following local guidelines. We report a case of posterior reversible encephalopathy syndrome in a patient with COVID-19 disease, possibly related to anti-IL-1 or anti-IL-6, suggesting that anti-interleukin treatments may cause this syndrome, at least in patients with predisposing conditions such as infections and hydroelectrolytic disorders. Keywords Posterior reversible encephalopathy syndrome (PRES) . COVID-19 . Anakinra . Tocilizumab . Immunomodulators
Introduction A 66-year-old woman with COVID-19 presented with adult respiratory distress syndrome (ARDS). Besides bilateral pneumonia, she developed multiple complications such as cardiorespiratory arrest, bacterial superinfection, hyponatremia, massive hemoptysis requiring embolization, and acute renal injury. She was started on lopinavir/ritonavir, hydroxychloroquine, and azithromycin. After radiological pulmonary progression, anti-IL-1 (daily anakinra) and anti-IL-6 (single dose of tocilizumab) were started, following local and hospital guidelines. These drugs are recommended in COVID-19 when there is clinical, blood test, or radiological progression, to avoid an excessive immunological systemic This article is part of the Topical Collection on COVID-19 * Laura Llansó [email protected] Xabi Urra [email protected] 1
Department of Neurology, Hospital Clínic, C/ Villarroel 170, 08036 Barcelona, Catalonia, Spain
2
Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Catalonia, Spain
response to the virus, which is thought to worsen pulmonary infiltrates and disease prognosis. Ten days after the initiation of immunodepressants, she developed altered mental status without fever, previous headache, or visual disturbances.
Case Presentation At the examination, the patient opened eyes to painful stimuli, had no verbal response, and showed withdrawal response to pain (Glasgow Coma Scale 7). The blood tests showed stable hyponatremia (130 mEq/L) and leukocytosis without any other significant findings. Her vitals were within normal limits, and blood pressure had been mildly increased during the previous 12 h with a maximum systolic pressure of 160 mmHg. Electrocardiogram showed sinus rhythm and
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