Posterior reversible encephalopathy syndrome in severe leptospirosis: A case report

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity with diverse aetiologies. It presents with headache, altered sensorium, seizures, and visual disturbances and is characterised by symmetrical white matter changes on neuroimaging. An acute rise in the blood pressure is the commonest cause of PRES. We report a patient who developed PRES in the recovery phase of severe leptospirosis. We discuss the interplay of possible patho-mechanisms of PRES in leptospirosis.

A 14-year-old Sri Lankan male presented with a 5-day history of high-grade fever and myalgia and a 2-day history of oliguria. Physical examination was unremarkable. Leptospirosis was diagnosed using the microscopic agglutination test. During hospitalisation, he developed acute kidney injury and pulmonary haemorrhage, requiring mechanical ventilation and treatment with intravenous ceftriaxone and daily plasma exchange. Both complications resolved by day 13 of the illness. On day 14, he developed sudden-onset altered consciousness followed by a generalised tonic-clonic seizure. There were no signs of meningism, and serum glucose, calcium, magnesium, and sodium levels were within normal limits. Brain MRI demonstrated symmetrical T2/FLAIR hyperintensities in the bilateral parieto-occipital white matter, consistent with PRES. Blood pressure at the time was 140/90 mmHg. Cerebral angiography excluded vasculitis. Neurological symptoms resolved spontaneously within 24 h, and the patient recovered fully.

PRES is an uncommon complication of severe leptospirosis. Clinicians should consider this diagnosis in patients with leptospirosis who develop acute encephalopathy or seizures.