1205

Abstract

Introduction: The posterior reversible encephalopathy syndrome (PRES) is manifested by headache and altered mental status with or without visual disturbances and seizures along with unique radiological findings. We present a case of 53 year old female with renal cell cancer who developed PRES after radical nephrectomy. Although PRES has been associated with hypertension and renal disease, and while there have been few case reports of postoperative PRES, this is the first case report to our knowledge of the syndrome occurring after a nephrectomy. A 53 year old female with well controlled hypertension and diabetes mellitus initially presented with several month history of weight loss, recurrent low grade fevers, and intermittent right lower quadrant pain. Upon imaging, she was found to have right renal mass with invasion of right renal vein and possible vertebral metastases. She underwent right radical nephrectomy with regional lymph node removal. On third post operative day, the patient developed chest pain and EKG changes and was started on anticoagulation with heparin along with aspirin and plavix. Subsequently on post operative day five, she started complaining of headache, nausea, vomiting and rapidly developed altered mental status and loss of vision without any other focal neurological weakness or ataxia. Previously well controlled blood pressure started to rise, with mean arterial pressure now ranging between 100-120 mm of Hg. Brain MRI revealed new onset edema tracking along the bilateral posterior occipital lobe white matter compatible with PRES. Also seen were right subarachnoid hemorrhage and intra-parechymal petechial hemorrhage. She received fresh frozen plasma and platelet transfusions along with strict blood pressure control with intravenous anti hypertensives. Patient had rapid recovery with resolution of altered sensorium over the next 24 hours and improvement in her visual symptoms in 48-72 hours. Patient was subsequently discharged home. We report a unique case of development of PRES syndrome occurring after nephrectomy. Our case highlights importance of early recognition of the syndrome and strict blood pressure control in such settings.