Dados do Trabalho

Título

Posterior Reversible Encephalopathy Syndrome associated with post-vaccination Guillain-Barré Syndrome, would it be possible?

RESUMO

Presentation of the Case
70-year-old female with hypertension, obesity and anxiety, taking atenolol and citalopram. Admitted with weakness after 7 days of receiving the Janssen-COVID19 vaccine. She evolved with hyperactive delirium, in addition to paraparesis and hyporeflexia that were difficult to assess, admitted to the ICU for delirium control.
Head CT with signs of subarachnoid hemorrhage (SAH) in cortical sulci in the frontal right convexities. Cerebral angiography initially without any vascular. She had been presenting with tachycardia and hypertension despite treatment.
She presented worsening of the motor condition and after 7 days of control of the delirium. Brain MRI was performed showing hypersignal in T2/FLAIR cortico-subcortical in the gyri of the convex encephalic convexities, symmetrical, notably frontoparieto and occipital, without restriction on diffusion; suggesting as posterior reversible encephalopathy syndrome (PRES). The RCVS2 score was 5. Nimodipine was started, and increased intracranial artery velocities were observed on transcranial Doppler. After 2 weeks, presented with sudden cortical blindness; then submitted to arteriography showing diffuse vasospasm in addition to areas of subocclusion in P3 left segments, and received intra-arterial milrinone. For 15 days, she had continuous milrinone and noradrenaline and nimodipine until the vasospasm improved. Control MRI showed areas of right frontal, bilateral parieto-occipital and right cerebellar subacute/chronic ischemic events. CSF with protein-cytological dissociation, was submitted to plasmapheresis, due to a post-vaccination Guillain-Barré Syndrome (GBS) confirmed by an electroneuromyography study.
Evolved with improvement of the delirium, treating neuropathic pain and motor rehabilitating.
Discussion
Recognition of non-aneurysmal SAH causes is still a challenge for the clinician. Systemic assessment of the patient and not just the neurovascular condition is extremely important to recognize the PRES and its possible triggering factors; despite uncertainties regarding the pathophysiology of a minority of cases evolving with unfavorable outcomes.
Final comments.
The association of GBS with a post-vaccination condition is already well established in the literature, but with few reported cases of association with PRES of severe evolution. Despite the use of medication known to be associated with some antidepressant medications; its association with GBS is poorly described.

Palavras Chave

Posterior Reversible Encephalopathy Syndrome, Reversible Cerebral Vasoconstriction Syndrome, Guillain-Barre Syndrome