Posterior Reversible Encephalopathy Syndrome Associated with COVID-19 in a Japanese Patient

A woman in her early 90s was being treated for coronavirus disease 2019 (COVID-19). Computed tomography (CT) of the chest showed bilateral ground-glass opacities and a “crazy-paving” pattern, which have been reported as findings of COVID-19 infection (1). She had a history of hypertension and was regularly taking angiotensin II receptor blockers and calcium channel blockers. On admission, her blood pressure was 131/63 mmHg. On the third hospital day, she presented to our hospital with seizures, confusion, and right hemiplegia. Her D-dimer levels were elevated (7.9 μg/mL). Brain CT showed low-density areas predominantly affecting the posterior regions bilaterally (Picture A-C). Clinical symptoms and CT findings were suggestive of posterior reversible encephalopathy syndrome (PRES). On the day of PRES onset, she missed her daily doses of antihypertensive medicines due to confusion, and her blood pressure was 160/77 mmHg. Treatment with an anti-epileptic drug improved her symptoms. Some cases of PRES have been reported to occur in patients with COVID-19 infection (3, 4). While the mechanism underlying this association is unclear, the combination of disordered cerebrovascular autoregulation and inflammation has been considered to play a role (2). Furthermore, our patient had no history of autoimmune diseases and had not been treated with calcineurin inhibitors (2). In the clinical setting, it is somewhat difficult to obtain timely brain images of patients with severe COVID-19 symptoms. In fact, we were unable to evaluate brain magnetic resonance imaging or follow-up CT in this case. However, our initial CT findings may be helpful for clinicians treating COVID-19 patients, as PRES appears to be a rare condition [only 1 case (0.17%) reported among 600 COVID-19 patients treated at our hospital between January 2020 and January 2021]. Future studies should focus on the further exploration of the association between PRES and COVID-19.