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Posterior reversible encephalopathy syndrome: case report A 75-year-old woman developed posterior reversible encephalopathy syndrome (PRES) during antibiotic treatment with ciprofloxacin and metronidazole. The woman, who had a history of anemia, hypothyroidism, renal failure and hypertension, and recent abdominal abscess with diverticulitis which required treatment with metronidazole and ciprofloxacin [routes not stated], presented to the emergency department from a rehabilitation center with fatigue, vomiting/nausea, confusion and increased somnolence. The planned treatment with metronidazole and ciprofloxacin was 4 weeks after the last incision and drainage. CT scan of abdomen ruled out an abdominal abscess. Subsequently, she developed seizure-like activity and she was intubated immediately. She was euglycaemic and hypotensive before and after intubation. Laboratory tests revealed elevated serum creatinine level from 1.6 to 1.8 mg/dL. After investigation, it was found that she had no history of seizures. The woman was treated with levetiracetam with resolution of seizures. During her course in the emergency department, it was found that she had been receiving metronidazole 500mg twice daily and ciprofloxacin 500mg twice daily for the past 3 weeks. Following intubation, brain MRI was performed, which revealed bilateral symmetric areas of increased T2/FLAIR signal intensity in the deep subcortical white matter of the parietal occipital regions consistent with PRES. During day 1, she was transferred to the medical ICU. Due to her requirement of antibiotics, she continued receiving metronidazole. However, ciprofloxacin was switched to aztreonam, and vancomycin was added empirically to her antibiotic regimen for a workup of sepsis. She had leukocytosis and hypotension indicating sepsis. On day 2, she remained intubated. Her serum creatinine increased to 4 mg/dL. Thus, unspecified vasopressors support was given. On day 3, electroencephalogram was performed, which revealed diffuse encephalopathy with bifrontal cortical dysfunction. On day 4, she was weaned off all sedation. She had no seizure-like activity. However, she remained unable to follow commands. Hence, her treatment with vancomycin, aztreonam and metronidazole were discontinued. Subsequently, her serum creatinine level started decreasing from 4 to 3 to 2.6 mg/dL. On day 5, she was able to follow commands. Subsequently, she was extubated. The serum creatinine level decreased to 2.4 mg/dL. She had no seizure activity. On day 8, she was transferred to the general medicine ward. She continued to regain her strength gradually and by day 15 she was near-baseline strength. On day 18, a brain MRI was performed, which revealed complete resolution of PRES. On the same day, she was discharged back to the rehabilitation center. A diagnosis of PRES induced by metronidazole and ciprofloxacin was made. Her concomitant renal failure also contributed in the development of PRES. A Naranjo Adverse Drug Reaction Probability Scale was 5 for metronidazole and ciprofloxacin, wh