Posterior Reversible Encephalopathy Syndrome Following Blood Transfusion: A Rare Case Report with Literature Review

Posterior reversible encephalopathy syndrome (PRES) is clinicoradiological disease entity characterized by headache, seizures, altered sensorium and corticalvisual loss with characteristic MRI features of subcortical white matter hyperintensities on T2W imaging. Though hypertension is a traditional hallmark of PRES, uncommon causes without hypertension have been described. We report an unusual such case without hypertension, precipitated by red cell transfusion.

A 40 years female received six units of packed cell transfusion for severe anemia (Hemoglobin 3.0 Gm %) transfused over 8 hours. She was having menorrhagia and was operated on for a hysterectomy. She developed a headache on the second postoperative day for five days and no cause was revealed in spite of extensive workup, including MRI brain and CSF study. On the sixth day, she had recurrent seizures followed by altered sensorium in the absence of hypertension. Her repeat MRI brain findings were consistent with PRES.

We reviewed 25 cases, including the present one as PRES after the blood transfusion. 24 were females, and 16 of 19 developed PRES in the course of chronic anemia lasting over 1 month. Anemia was severe in 18 of 25 cases, with haemoglobin (Hb) levels < 4.0 Gm%. In 16 of 20 cases, Hb levels increased to 5 g/dl by red cell blood transfusion until the onset of PRES. On MRI brain, 23 of 25 cases showed vasogenic edema and 3 of 25 cases showed an irreversible neurological deficit. When treating severe chronic anemia rapid correction of Hb with blood transfusion, one should consider a possibility of PRES in post-transfusion neurological symptoms in spite of normal diagnostic workup.