Posterior Reversible Leukoencephalopathy Syndrome After Rituximab A Rare but Severe Complication

Introduction: Posterior Reversible Encephalopathy Syndrome (PRES) is a neurological disorder presenting with seizures, headaches, visual disturbances, and altered consciousness. It has been linked to conditions like uncontrolled hypertension (HTN), thrombotic thrombocytopenic purpura (TTP), and immunosuppressive treatments. While PRES typically occurs after the first dose of Rituximab, this case highlights its occurrence after a second dose.

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Case Overview: A 23-year-old female with resistant TTP, previously treated with steroids and plasmapheresis, was admitted with renal failure, severe fluid overload, and lower respiratory tract infection. Due to worsening thrombocytopenia, she received Rituximab as an adjunct therapy. The first dose was well-tolerated; however, 48 hours after the second dose, she developed uncontrolled HTN (190/110 mmHg), generalized tonic-clonic seizures, and altered sensorium, requiring mechanical ventilation. MRI findings confirmed PRES.

Seizures remained uncontrolled despite conventional therapy. The patient underwent two consecutive plasmapheresis cycles, which successfully resolved the seizures. Unfortunately, she later developed ventilator-associated pneumonia and sepsis, leading to withdrawal of ventilatory support by her family.

Understanding PRES and Its Link to Rituximab: PRES is characterized by vasogenic edema predominantly affecting the occipital and posterior parietal lobes. While commonly associated with hypertension and immunosuppressive drugs, Rituximab has been increasingly reported as a trigger.

According to the American College of Radiology (ACR), early detection through MRI is crucial in diagnosing PRES, allowing timely intervention and preventing complications.

Key Takeaways:

• PRES presents with neurological symptoms and is confirmed through MRI.
• Rituximab, widely used for autoimmune diseases and hematologic malignancies, has been implicated in PRES cases.
• Management includes blood pressure control, discontinuation of the causative drug, and, in severe cases, plasmapheresis.

Read the full study at https://doi.com10.29328/journal.jcn.1001010.

Final Thoughts: This case underscores the importance of monitoring patients receiving Rituximab for signs of PRES. Awareness among healthcare professionals can facilitate early intervention and improve patient outcomes.

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