Hypertension and encephalopathy in a pediatric patient following red blood cell transfusion

Post-transfusion encephalopathy is a rare complication of red blood cell transfusions. Diagnostic entities include reversible cerebral vasoconstriction syndrome (RCVS) and posterior reversible encephalopathy syndrome (PRES), which can be difficult to distinguish. These have primarily been reported in adults with severe chronic anemia. There are limited reports of these entities occurring in children after transfusions; most reported cases have clear pre-existing risk factors.

Here we describe a 4-year-old male who presented with altered mental status 5 days after being treated for severe iron-deficiency anemia with large volume packed red blood transfusions, where his hemoglobin was increased from 1.4 to 11.4 g/dL over 70 h. Brain magnetic resonance imaging was concerning for RCVS/PRES. He made a complete neurologic recovery after 8 days with aggressive blood pressure control with calcium channel blockers.

Though this case had features of both RCVS and PRES, his hypertension and encephalopathy were in retrospect most consistent with PRES. This case highlights both the diagnostic challenges related to and important features of transfusion-related cerebral pathology, including large volume red blood cell transfusion for severe chronic anemia, even when administered over multiple days. Prompt recognition of transfusion-related neurologic disease is critical for appropriate management.