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Título

REVERSIBLE POSTERIOR ENCEPHALOPATHY SYNDROME IN A YOUNG PATIENT WITH PRIMARY MALIGNANT ARTERIAL HYPERTENSION: CASE REPORT

RESUMO

CASE PRESENTATION:
P.S.B, male, 29 years old, low visual acuity 3 months ago, hypertension requiring sodium nitroprusside in an infusion pump, altered level of consciousness, and convulsive crisis. Patient with no comorbidities. In ophthalmological evaluation, there is evidence of bilateral papilledema, increased vascular tortuosity, bilateral microaneurysms and microhemorrhages, and visual acuity of hand movement. Initially, skull tomography (CT) presented diffusely hypodensity in white matter and hydrocephalus. In cerebrospinal fluid, presence of protein increase, and alteration of renal function compatible with chronic kidney disease.
This was followed by hypotheses of diseases of the white substance of inflammatory, infectious, neoplastic or vascular origin. In Cranial Magnetic Resonance Imaging (MRI), hypersignal in FLAIR in supra and infratentorial white matter, in optic nerves and ventricular ectasia. Intracranial arterial angiography without alterations. Brain biopsy was also performed, with a normal result. Serological, infectious and rheumatological tests negative, and normal abdominal MRI and renal arteriography.
After satisfactory blood pressure control, the patient presented complete improvement of mental confusion, absence of new convulsive crises and partial improvement of visual deficit. On cranial MRI performed after one month of hospitalization, there was a significant reduction in the lesions. Given the diagnostic exclusions and patient evolution, the diagnosis of Reversible Posterior Encephalopathy Syndrome (PRES) was confirmed.
DISCUSSION:
The PRES course with altered level of consciousness, visual deficits, headache, convulsive crises and focal deficits. There are divergences on the pathophysiology, believing that the main point is endothelial damage with vascular extravasation, resulting in edema. It translates as hypodensity on CT and hypersignal on cranial MRI, predominantly in occipital and parietal lobes, but not exclusively. It may be secondary to severe arterial hypertension, chronic kidney disease, sepsis, and immunosuppression. In the differential diagnoses we found infections, autoimmune diseases, vasculitis, malignant diseases and basilar artery thrombosis. The treatment does not control the primary etiology.
FINAL COMMENTS:
Atypical and/or infratentorial PRES is less common, but in the face of a classic clinical picture with a typical triggering factor should be part of the differential diagnosis of white matter diseases.

Palavras Chave

PRES, Malignant arterial hypertension, atypical