(686) A Shocking PRESentation of Posterior Reversible Encephalopathy Syndrome

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological diagnosis that presents with varied neurological symptoms including altered mentation and seizures, plus a characteristic MRI appearance of vasogenic edema in bilateral cerebral regions. Typical precipitants for PRES are acute hypertension, renal disease or exposure to drugs leading to endothelial dysfunction and cerebrovascular dysregulation especially within posterior circulation vessels. Septic shock patients are hypotensive rather than hypertensive but the systemic inflammation and cascading cytokine release leads to similar endothelial dysfunction, tissue permeability and cerebral edema if intracranial vessels are involved. We present a case of PRES precipitated by decompression of ureteral obstruction in the setting of urosepsis and septic shock.

Description: 64 yo female presented with fever, dysuria and flank pain; diagnosed with pyelonephritis and hydronephrosis from obstructing 5mm left ureteric stone. Underwent cystoscopy and ureteral stent placement. Immediately post-procedure developed septic shock requiring vasopressors but also endorsed new vision loss. Initial exam suggested global encephalopathy without focal neurologic deficits but closer examination revealed impairment in cortical visual processing. Able to clearly write complex sentences as they were dictated but was unable to read what she had written; diagnosed with alexia without agraphia. MRI brain showed vasogenic edema in bilateral occipital lobes. Our patient had improvement of visual and cognitive deficits by individualizing hemodynamic goals to support both systemic and effective cerebral perfusion. Neuroimaging 6-weeks later demonstrated resolution of posterior vasogenic edema.

Discussion: In our case there was a temporal relationship between ureteric decompression, septic shock and onset of encephalopathy with cortical visual deficits. The septic inflammatory response was likely heightened by sudden cytokine release after ureteric stent placement, leading to significant cerebrovascular dysregulation and cerebral edema.The prompt recognition of PRES allowed us to individualize hemodynamic management during septic shock to support cerebral perfusion and neurological recovery.