Staff Anesthesiologist Cleveland Clinic Cleveland, Ohio, United States
Introduction: Posterior Reversible Encephalopathy Syndrome (PRES) is characterized by altered mental status, headaches, seizures, and hemiparesis, often with MRI showing parietooccipital hyperintensities on T2-weighted imaging. Diagnosing PRES is challenging due to the lack of formal criteria and multiple predisposing factors, including severe hypertension, renal failure, immunosuppression, sepsis, and autoimmune conditions. We present a rare case of hypercalcemia-induced PRES in a post-transplant patient, emphasizing its unusual etiology.
Description: A 61-year-old female with familial adenomatous polyposis underwent an intestinal transplant. Two months later, she presented with altered mental status, elevated blood pressure (168/80 from baseline 119/81), acute kidney injury (creatinine 2.8 mg/dL from baseline 0.8 mg/dL), and hypercalcemia (14.3 mg/dL). Lumbar puncture was negative for infection. CT and MRI showed bilateral thalamic and occipital hyperintensities on T2-weighted imaging, consistent with PRES. Initially, PRES was attributed to tacrolimus, and her immunosuppression was switched to cyclosporine, while hypercalcemia was managed with furosemide, leading to improvement and discharge with baseline function. Three months later, she returned with worsened mental status, elevated blood pressure (200/90), acute kidney injury (creatinine 2.35 mg/dL), and hypercalcemia (15.6 mg/dL). CT did not reveal intracranial abnormalities, and MRI was not performed. Malignancy workup was negative. Correcting hypercalcemia led to improvement, revising the diagnosis to hypercalcemia-induced PRES—a notably rare cause. She was discharged with baseline mental status, and follow-ups revealed no new neurological symptoms.
Discussion: While PRES secondary to tacrolimus is well-documented, hypercalcemia-induced PRES is rare but important to consider. This case emphasizes the challenge of diagnosing PRES in post-transplant patients with complex medical history. It highlights the need for a high index of suspicion for unusual causes like hypercalcemia, in addition to common factors such as hypertension, acute kidney injury, and immunosuppression. Successful management requires correct diagnosis, prompt treatment and a multidisciplinary approach.
