Diabetic ketoacidosis-induced posterior reversible encephalopathy syndrome (PRES)

Case contributed by Ibrahim M. Jubarah
Diagnosis probable

Presentation

History of acute severe abdominal pain, fever, and urinary tract infection. Intubated due to subsequent neurological compromise and a diagnosis of diabetic ketoacidosis and hypernatremia. Abdominal imaging was normal. No past medical or surgical history.

Patient Data

Age: 16 years
Gender: Female

No definite CT signs of intracranial hemorrhage, brain edema, or mass lesion.

Bilateral almost symmetrical areas of restricted diffusion involving the centrum semiovale white matter, corpus callosum, and to a lesser extent the frontotemporoparietal cortex, anterior thalami, external capsule, and posterior limb of the internal capsule, sparing the basal ganglia and brainstem.

Subtle hyperintensity in some corresponding areas on T2WI and FLAIR sequences, including the centrum semiovale bilaterally.

The patient was extubated and later developed vision loss, tonic-clonic convulsions, and quadriparesis after about a week. Another MRI and MRV study was done.

Bilateral almost symmetrical cortical and subcortical confluent hyperintensity on T2WI and FLAIR sequences in areas of the parietal and occipital lobes, with corresponding hypointensity on T1WI, and multiple T2WI/FLAIR hyperintense foci in the subcortical white matter of both frontal lobes, without diffusion restriction or hemorrhagic components.

Normal MRV study.

Case Discussion

The patient presented with neurological deficits and was found to have hypernatremia and diabetic ketoacidosis, with urinary tract infection.

The brain CT scan showed no definite features of brain pathology.

The first MRI study was suggestive of early changes of diabetic ketoacidosis-associated ischemia, extrapontine myelinolysis, or an intervening event of hypoglycemia, which could be reversible changes.

After about a week, the patient developed new neurological deficits, including vision loss, tonic-clonic convulsions, and quadriparesis.

Another MRI and an MRV study revealed vasogenic edema mainly involving the posterior cerebral hemispheres (areas of almost symmetrical posterior vascular territories) without restricted diffusion or venous sinus thrombosis, typical and suggestive of posterior reversible encephalopathy syndrome (PRES). This study also demonstrates multiple T2W/FLAIR hyperintense variable-sized foci, mainly subcortical cerebral bilaterally, which could be related to changes seen on the previous study or new changes.

The condition clinically exhibited marked progressive improvement in the next few days and was planned for follow-up. Meanwhile, the likely diagnosis is diabetic ketoacidosis-induced posterior reversible encephalopathy syndrome.

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