Posterior reversible encephalopathy syndrome in a young male with IgA nephropathy and chronic kidney disease: a case report from the Maldives

Background

Posterior reversible encephalopathy syndrome (PRES) is characterized by acute cerebral endothelial dysfunction, leading to a disruption of the blood–brain barrier and resulting in vasogenic edema [1, 2]. Although it can affect people of all ages, it is more common in younger and middle-aged adults [2]. PRES usually affects the posterior circulation of the brain, but it can also involve other areas [1, 3, 4]. Patients with hypertension, CKD, ongoing dialysis, pregnancy, and sepsis and those on immunosuppressants are at higher risk of developing PRES [1, 3, 4]. Symptoms can vary depending on which part of the brain is affected and can include headaches, vision changes, seizures, and neurological deficits [5]. Mortality rate of PRES is around 16–19%, and about 44% of patients are left with varying degrees of functional impairments [6, 7]. This report discusses a case of PRES in a young male with underlying IgA nephropathy.

Case presentation

A 27-year-old male with past medical history of IgA nephropathy presented with a 2-day history of generalized throbbing headache, nausea, and vomiting and 1-day history of reduced urine output. There was no history of limb weakness, fever, neck stiffness, or altered sensorium.

The diagnosis of IgA nephropathy was made 2 years back, following a renal biopsy. He is currently on prazosin, sevelamer, allopurinol, and calcitriol.

On examination, he appeared to be well built, alert, conscious, and oriented with a blood pressure of 172/122 mmHg, axillary temperature of 36.9 °C, heart rate of 60 beats/minute, and respiratory rate of 20 breaths/minute. There was no pallor or edema. Systemic examination including central nervous system examination was unremarkable. Visual acuity and visual field were normal. Bedside fundus examination revealed absence of papilledema.

Laboratory results revealed a hemoglobin of 10.3 g/L, packed cell volume (PCV) of 30.3%, and platelet count of 154 × 10⁹/L. Serum creatinine was 17.3 mg/dL, and serum urea was 263.22 mg/dL. Arterial blood gas showed a pH of 7.22, bicarbonate of 14.5 mEq/L, and partial pressure of carbon dioxide (PCO₂) of 35.4 mmHg.

During the admission, he developed blurring of vision and 2 episodes of seizures.

Computed tomography (CT) of the brain showed ill-defined areas of hypodensity predominantly involving the subcortical white matter at the bilateral parieto-occipital lobes (Fig. 1). MRI of the...