To: Posterior reversible encephalopathy syndrome in a child with severe multisystem inflammatory syndrome due to COVID-19 - Critical Care Science (CCS)
Crit Care Sci. 2023;35(4):427-428
We read with interest the article by Dominguez-Rojas et al. about a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR)-negative 9-year-old male who underwent laparotomy for suspected acute abdomen (vomiting, abdominal pain, diarrhea), which was noninformative.() On postoperative day one, the patient experienced respiratory insufficiency attributed to pneumonia with pleural effusion requiring mechanical ventilation and noradrenergic support.() Although weaning was feasible 15 days after intubation, the patient deteriorated again, manifesting with bilateral plantar fasciitis, delusions, suicidal ideation, psychomotor agitation, and two generalized seizures.() Cerebral magnetic resonance imaging (MRI) revealed bilateral T2 hyperintensities in the white matter of the occipital lobes, leading to a diagnosis of posterior reversible encephalopathy syndrome (PRES) due to multisystem inflammatory syndrome in childhood; the patient was successfully treated with intravenous immunoglobulins, resulting in almost complete recovery at the three-week follow-up after discharge.() The study is appealing but raises concerns that should be discussed.
We disagree with the diagnosis of PRES. The PRES is usually associated with arterial hypertension.() However, the patient had no history of arterial hypertension and either arterial hypotension or normal blood pressure values during hospitalization in the intensive care unit.() Were elevated blood pressure values ever measured? Although PRES can also develop in the absence of arterial hypertension,() this is rather rare. Differential diagnoses that should have been ruled out include cerebral hypoxia (the patient experienced hypoxia prior to intubation), acute disseminated encephalomyelitis (ADEM), immune encephalitis, and venous sinus thrombosis. A shortcoming in this respect is that the patient did not undergo investigations of the cerebrospinal fluid. Cerebrospinal fluid investigations are necessary to particularly rule out ADEM and encephalitis.
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We read with interest the article by Dominguez-Rojas et al. about a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR)-negative 9-year-old male who underwent laparotomy for suspected acute abdomen (vomiting, abdominal pain, diarrhea), which was noninformative.() On postoperative day one, the patient experienced respiratory insufficiency attributed to pneumonia with pleural effusion requiring mechanical ventilation and noradrenergic support.() Although weaning was feasible 15 days after intubation, the patient deteriorated again, manifesting with bilateral plantar fasciitis, delusions, suicidal ideation, psychomotor agitation, and two generalized seizures.() Cerebral magnetic resonance imaging (MRI) revealed bilateral T2 hyperintensities in the white matter of the occipital lobes, leading to a diagnosis of posterior reversible encephalopathy syndrome (PRES) due to multisystem inflammatory syndrome in childhood; the patient was successfully treated with intravenous immunoglobulins, resulting in almost complete recovery at the three-week follow-up after discharge.() The study is appealing but raises concerns that should be discussed.
We disagree with the diagnosis of PRES. The PRES is usually associated with arterial hypertension.() However, the patient had no history of arterial hypertension and either arterial hypotension or normal blood pressure values during hospitalization in the intensive care unit.() Were elevated blood pressure values ever measured? Although PRES can also develop in the absence of arterial hypertension,() this is rather rare. Differential diagnoses that should have been ruled out include cerebral hypoxia (the patient experienced hypoxia prior to intubation), acute disseminated encephalomyelitis (ADEM), immune encephalitis, and venous sinus thrombosis. A shortcoming in this respect is that the patient did not undergo investigations of the cerebrospinal fluid. Cerebrospinal fluid investigations are necessary to particularly rule out ADEM and encephalitis.
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