Posterior reversible encephalopathy syndrome with guillain barre syndrome: rare, coincident and preventable

Abstract

Posterior reversible encephalopathy syndrome (PRES) is clinico - radiologic entity associated with hypertensive emergency, autoimmune disease, chemotherapeutic drugs etc. Concurrent occurrence of Guillain-Barre syndrome (GBS) with PRES is a rare entity. Acute rise in blood pressure (BP) due to dysautonomia increases cerebral blood flow causing vasogenic edema, manifests with headache, nausea, vomiting, seizures, altered sensorium, visual abnormalities, and focal neuro deficits (1). MRI imaging characteristics of PRES consist of hyperintense areas in the parieto-occipital region and features of vasogenic edema. 59 year housewife presented with two days history of ascending weakness progressively involving neck, trunk and upper limbs. Clinical diagnosis of GBS was considered and plasmapheresis was started. She was treated with betablockers for high BP. Subsequently she developed generalized seizures and altered sensorium. She was intubated, ventilated and AED were introduced. MRI brain consistent with clinical suspicion of PRES (Fig 1). Antihypertensives were titrated with target BP ≤130/80 mm hg. Plasmapheresis course was completed, limb power improved and she was extubated. MRI Brain after two weeks revealed near complete interval regression of the lesions (Fig 2). Antihypertensives, antiepileptics were optimised, neurorehabilitation continued and she was discharged at two weeks with advice for rehabilitation for her motor weakness. Autonomic dysfunction which occurs in association with GBS is at times challenging particularly during plasmapheresis and may lead to this complication. It is important to be aware of this complication so that early recognition would avoid morbidity.