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Atypical imaging findings in a renal transplant patient with reversible posterior leukoencephalopathy syndrome: a case report

Soler Riera C, Haddad L, Scocco D, Fischer G, Saubidet CL, Alvarez PA - Cases J (2009)

Bottom Line: Ischemic stroke was diagnosed and aspirin and permissive hypertension were indicated.Twelve hours later he developed left sided motor seizures and cortical blindness.Magnetic Resonance Image showed hyper intensity in T2 and FLAIR in both occipital lobes and a small area of cortical restricted diffusion in Diffuson Weighted Images in the left occipital lobe.

Affiliation: Department of Internal Medicine, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Av Las Heras 2900 (C1425ASS), Buenos Aires, Argentina.

ABSTRACT

Background: Atypical clinical and imaging findings in Reversible Posterior Leukoencephalopathy Syndrome are recognized with increasing frequency.

Case report: We report a case of an adult in his 5(th )decade immunosupressed with methilprednisolone, tacrolimus and micophenolate who two months after renal transplantation, multiple infections and an episode of humoral rejection became hypertensive with severe headaches, visual field abnormalities, seizures, left hemiparesis and hemineglect. Computed Tomography scan of the brain showed a hypo dense lesion in the left occipital lobe. Ischemic stroke was diagnosed and aspirin and permissive hypertension were indicated. Twelve hours later he developed left sided motor seizures and cortical blindness. Magnetic Resonance Image showed hyper intensity in T2 and FLAIR in both occipital lobes and a small area of cortical restricted diffusion in Diffuson Weighted Images in the left occipital lobe. With a diagnosis of Reversible Posterior Leukoencephalopathy Syndrome his blood pressure was controlled with intravenous labetalol, and two days later the neurologic findings returned to baseline and most Computed tomography findings resolved.

Conclusion: This case underscores that in the appropriate setting Reversible Posterior Leukoencephalopathy Syndrome should be suspected and the clinician should not be misled by atypical clinical or imaging findings. In contrast to other pathologies that resemble Reversible Posterior Leukoencephalopathy Syndrome, with the right and timely treatment, signs, symptoms and images can be completely reversible.

Brain MRI T2 Bilateral parieto-occipital hyperintese lesion.
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Figure 4: Brain MRI T2 Bilateral parieto-occipital hyperintese lesion.

Mentions: Twelve hours later he had an episode of left-sided motor focal seizures followed by left hemiparesis and was admitted to the intensive care unit. He was alert and oriented. Blood pressure was 165/71, temperature 36.3°C, heart rate 88, pulse oximetry 100% on room air, respiratory rate 18. The neurological exam showed left arm and left leg weakness and bilateral amaurosis. A new CT scan showed bilateral occipital hypodensities and hemorrhagic foci. (Figure 2) Diphenilhydantoin was started. Brain Magnetic Resonance Image (MRI) showed bilateral occipital hyperintese lesions in Fluid Attenuated Inversion Recovery (FLAIR) and T2, a small area of cortical left occipital lobe restricted diffusion on Diffusion Weighted Image (DWI) and GRE sequence compatible with hemorrhage. (Figure 3, 4, 5, 6) MRI venous and arterial angiography showed no abnormalities. (Figure 7,8)

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Atypical imaging findings in a renal transplant patient with reversible posterior leukoencephalopathy syndrome: a case report

Soler Riera C, Haddad L, Scocco D, Fischer G, Saubidet CL, Alvarez PA - Cases J (2009)

Brain MRI T2 Bilateral parieto-occipital hyperintese lesion.
© Copyright Policy
Figure 4: Brain MRI T2 Bilateral parieto-occipital hyperintese lesion.
Mentions: Twelve hours later he had an episode of left-sided motor focal seizures followed by left hemiparesis and was admitted to the intensive care unit. He was alert and oriented. Blood pressure was 165/71, temperature 36.3°C, heart rate 88, pulse oximetry 100% on room air, respiratory rate 18. The neurological exam showed left arm and left leg weakness and bilateral amaurosis. A new CT scan showed bilateral occipital hypodensities and hemorrhagic foci. (Figure 2) Diphenilhydantoin was started. Brain Magnetic Resonance Image (MRI) showed bilateral occipital hyperintese lesions in Fluid Attenuated Inversion Recovery (FLAIR) and T2, a small area of cortical left occipital lobe restricted diffusion on Diffusion Weighted Image (DWI) and GRE sequence compatible with hemorrhage. (Figure 3, 4, 5, 6) MRI venous and arterial angiography showed no abnormalities. (Figure 7,8)

Bottom Line: Ischemic stroke was diagnosed and aspirin and permissive hypertension were indicated.Twelve hours later he developed left sided motor seizures and cortical blindness.Magnetic Resonance Image showed hyper intensity in T2 and FLAIR in both occipital lobes and a small area of cortical restricted diffusion in Diffuson Weighted Images in the left occipital lobe.

Affiliation: Department of Internal Medicine, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Av Las Heras 2900 (C1425ASS), Buenos Aires, Argentina.

ABSTRACT

Background:

Background: Atypical clinical and imaging findings in Reversible Posterior Leukoencephalopathy Syndrome are recognized with increasing frequency.

Case report: We report a case of an adult in his 5(th )decade immunosupressed with methilprednisolone, tacrolimus and micophenolate who two months after renal transplantation, multiple infections and an episode of humoral rejection became hypertensive with severe headaches, visual field abnormalities, seizures, left hemiparesis and hemineglect. Computed Tomography scan of the brain showed a hypo dense lesion in the left occipital lobe. Ischemic stroke was diagnosed and aspirin and permissive hypertension were indicated. Twelve hours later he developed left sided motor seizures and cortical blindness. Magnetic Resonance Image showed hyper intensity in T2 and FLAIR in both occipital lobes and a small area of cortical restricted diffusion in Diffuson Weighted Images in the left occipital lobe. With a diagnosis of Reversible Posterior Leukoencephalopathy Syndrome his blood pressure was controlled with intravenous labetalol, and two days later the neurologic findings returned to baseline and most Computed tomography findings resolved.

Conclusion: This case underscores that in the appropriate setting Reversible Posterior Leukoencephalopathy Syndrome should be suspected and the clinician should not be misled by atypical clinical or imaging findings. In contrast to other pathologies that resemble Reversible Posterior Leukoencephalopathy Syndrome, with the right and timely treatment, signs, symptoms and images can be completely reversible.

View Similar Images In: Results  - Collection
View Article: Pubmed Central - HTML -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=2783101&rFormat=json&query=null&req=5