Hemorrhagic Posterior Reversible Encephalopathy Syndrome in a Pediatric Patient With Acute Lymphoblastic Leukemia: A Case Report

TL;DR

A child with relapsed leukemia developed a rare neurological condition with brain bleeding after seizures and high blood pressure.

Contribution

This case report documents hemorrhagic PRES in a pediatric patient with ALL relapse, highlighting its rare and severe presentation.

Findings

The patient exhibited neurological symptoms including seizures, gaze palsy, and visual field changes consistent with PRES.

MRI confirmed extensive PRES damage with hemorrhagic changes, with partial recovery observed over two weeks.

Residual hemorrhage was evident in follow-up imaging despite overall improvement in neurological status.

Abstract

Posterior reversible encephalopathy syndrome (PRES) is an uncommon yet severe neurological disorder characterized by a combination of clinical and radiological features. Common clinical presentations of PRES include headaches, seizures, altered mental status ranging from lethargy to coma, visual disturbances, and behavior changes.

This case report outlines the occurrence of hemorrhagic PRES in an 11-year-old girl with B-cell acute lymphoblastic leukemia (ALL) relapse. Hospitalized for ALL relapse, the patient underwent reinduction chemotherapy. On the ninth day of admission, she had a generalized tonic-clonic seizure with a blood pressure peak of 170/120 mmHg. Magnetic resonance imaging (MRI) and a seizure episode suggested PRES. Initially, after the first tonic-clonic seizure, the neurological examination was normal, but after the second seizure, the meningeal symptoms were negative, and gaze palsy and right-sided homonymous hemianopsia were observed; muscle strength was symmetrically reduced in the upper and lower extremities and reflexes were symmetrical and diminished. A bilateral Babinski reflex was observed at the time of examination; the patient had mild motor aphasia, and she opened her eyes only in response to tactile stimulation. A follow-up MRI four days after the second seizure episode showed extensive PRES damage with hemorrhagic changes. Over two weeks, the patient's neurological status and blood pressure gradually improved, with persistent changes in the visual field. Subsequent MRI revealed a significant reduction in PRES lesions, but residual hemorrhage measuring 6x4 cm remained evident.

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