id_809. PRESENTING TO THE ER: A CASE REPORT IN THE EMERGENCY DEPARTMENT
Wojciech S. Gaweł1, Jacek Szypenbejl1,2, Justyna M. Fercho1,2,3, Oskar G. Chasles1, Julia Nakoneczna1, Zuzanna Krasula1, Bogdan Jabłoński1, Weronika Jagieło1, Mariusz Siemiński2
1 Medical University of Gdańsk, Department of Emergency Medicine, Scientific Circle of Neurotraumatology, 17 Smoluchowskiego St. Gdańsk, Poland
2 Medical University of Gdańsk, Department of Emergency Medicine, 17 Smoluchowskiego St. Gdańsk, Poland
3 10th Military Research Hospital and PolyClinic SPZOZ, Department of Neurosurgery, 5 Powstańców Warszawy St, Bydgoszcz, Poland
INTRODUCTION: Posterior Reversible Encephalopathy Syndrome (PRES) is a rare neuroradiological entity with heterogeneous triggers and variable lesion distribution. Acute seizures, altered consciousness, and visual symptoms may mimic stroke, infection, demyelination, or toxic–metabolic encephalopathy. The primary pathology of PRES is unknown, but the hallmark is cerebral edema. To date, no universal criteria for the diagnosis of PRES exist; however, a characteristic clinical presentation and the neuroradiological findings appear to be the most widely accepted.
AIM(S): We aim to present an atypical, severe PRES course in a complex patient and emphasize the role of early neuroimaging and broad differential diagnosis in the ER and ICU settings.
METHOD(S): The study is a retrospective case report. Clinical, laboratory, and imaging data were obtained from the patient’s medical records.
RESULTS: A 35-year-old man with end-stage renal disease on dialysis, SLE, refractory hypertension, and ongoing immunosuppression was admitted after 5 days of unknown downtime with coma and suspected seizures. He presented in profound shock with severe metabolic derangements, coagulopathy, and extreme inflammatory markers. CT showed parieto-occipital white-matter hypodensities and edema suggestive of PRES; MRI confirmed extensive lesions, while MRA/MRV excluded RCVS and venous thrombosis. Despite seizure prophylaxis, the prolonged ICU stay was complicated by polymicrobial/fungal infections, major hemorrhagic events, catheter thrombosis, and progression of cerebral edema with hemorrhagic transformation on follow-up imaging, leaving persistent neurological deficits.
CONCLUSIONS: PRES should be considered in critically ill patients with renal failure, autoimmune disease, immunosuppression, and sepsis, even when presentation is dominated by shock and metabolic abnormalities. Rapid CT followed by confirmatory MRI is pivotal to differentiate PRES from competing diagnoses and to guide management and prognostication.
FINANCIAL SUPPORT: There was no financial support provided.