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Characteristics and Outcomes of Critically Ill Pediatric Patients with Posterior Reversible Encephalopathy Syndrome
Grace Fisler1, Mikhaela A Monty2, Nina Kohn3
1Department of Pediatrics, Graduate Medical Education Office, Steven and Alexandra Cohen Children's Medical Center of New York, 269-01 76th Ave New, Hyde Park, NY, 11040, USA. gfisler@northwell.edu.
Insights
Posterior reversible encephalopathy syndrome (PRES) in children is linked to immunosuppression, autoimmune disease, anemia, and hypertension. These factors increase mortality risk and hospital stay in pediatric PRES cases.
Area of Science:
- Pediatric Neurology
- Critical Care Medicine
- Radiology
Background:
- Posterior reversible encephalopathy syndrome (PRES) is a neurological condition characterized by reversible neurological symptoms and white matter edema.
- While widely described in adults, studies on pediatric PRES are primarily limited to case series and case-control studies.
Purpose of the Study:
- To investigate the clinical characteristics and associated factors of PRES in children.
- To compare pediatric PRES patients with age- and mortality-matched controls.
Main Methods:
- Retrospective chart review of pediatric patients under 21 years diagnosed with PRES.
- Comparison with controls matched for age and mortality risk using the Pediatric Index of Mortality-2 score.
- Analysis of clinical presentation, comorbidities, and outcomes.
Main Results:
- Sixteen PRES cases were identified in 13 pediatric patients (ages 5-17). Common symptoms included altered mental status (75%) and seizures (77%).
- PRES patients exhibited higher mortality rates (15% vs. 5%), longer hospital stays (13.1 vs. 4.6 days), and increased likelihood of autoimmune disease, immunosuppression, and anemia.
- Hypertension (Stage II) was more prevalent in PRES patients (100% vs. 41%), along with higher creatinine levels (2.35 vs. 0.90 mg/dL).
Conclusions:
- In critically ill children, immunosuppression, autoimmune disease, renal insufficiency, anemia, and hypertension are associated with PRES.
- No significant association was found between corrected serum calcium or sepsis and PRES in this pediatric cohort.
- These findings highlight key risk factors and comorbidities associated with PRES in children, informing prognosis and management.
Background/Objective:
Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiologic entity, typically manifesting as reversible neurological symptoms and signs of white matter edema on magnetic resonance imaging. PRES has been widely described in adults. Studies of PRES in children are mostly limited to case series and case controls.
Methods:
Retrospective chart review of patients under 21 years with PRES admitted at a tertiary children's hospital from 2011 to 2016. They were compared to controls matched for age and mortality risk using the Pediatric Index of Mortality-2 score. RESULTS: Sixteen cases of PRES were identified in 13 patients (ages 5-17 years, 46% male). PRES presented with altered mental status (75%), seizures (77%), headache (31%), and vision changes (23%). In patients who recovered (n = 11), median days to symptom resolution was three (range 1-8). PRES patients had a higher mortality rate (15% vs. 5%, p < 0.05) and higher mean length of stay (13.1 vs. 4.6 days) and were more likely to have autoimmune disease (p < 0.05), immunosuppression (p < 0.05), and anemia (p < 0.05). No PRES patients were diagnosed with epilepsy by last known follow-up, and all of whom had been started on an antiepileptic drug were discontinued within 13 months. Sepsis was suspected in 53% of PRES patients and 59% of controls (p = 1.00). All PRES patients had stage II hypertension, versus 41% of controls (p < 0.05). Average creatinine in PRES was 2.35 mg/dL compared to 0.90 mg/dL in controls (p < 0.05). PRES patients had lower serum calcium (p < 0.05). After correcting for albumin, no association between PRES and hypocalcemia remained. PRES patients had a higher length of stay (13.1 vs. 4.6 days, p < 0.05) and mortality rate (15% vs. 3%, p < 0.05).
Conclusions:
Immunosuppression, autoimmune disease, renal insufficiency, anemia, and hypertension are associated with PRES after controlling for mortality risk in critically ill children. There was no association between corrected serum calcium and sepsis with PRES.
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