Background Posterior reversible encephalopathy syndrome (PRES) following the development of diabetic ketoacidosis (DKA) is rare and usually occurs in children. This is the first case of DKA following PRES that we know of that occurred in an adult.
Case report We encountered a middle-aged woman with a one-day history of nausea and vomiting who presented with DKA and seizure, along with hallucinations. On presentation, we performed physical examinations and blood biochemistry tests to ascertain the cause of these symptoms. We also performed magnetic resonance imaging (MRI) of her brain, which showed typical brain edema in the bilateral occipital and parietal regions, which indicated PRES. We treated the patient’s symptoms by administering adequate hydration and administering an infusion of insulin of 30 U after breakfast and 15 U after dinner to bring her blood sugar levels under control.
The brain MRI we performed showed hyperintensity of the bilateral occipital and parietal cortexes on a fluid-attenuated inversion recovery T2 weighted image, after which the patient was diagnosed with PRES. The patient was discharged thirteen days after admission with stable blood sugar and blood pressure levels.
Conclusions Physicians should keep this condition in mind as a possible complication of DKA and treat it quickly and efficiently in order to attain a good patient outcome.
This is the first report of DKA-induced PRES in an adult, and physicians should keep this condition in mind as a possible complication of DKA, which is treatable and may have a good prognosis.
Diabetic ketoacidosis (DKA) is a serious complication of diabetes mellitus. The most common neurologic imaging finding in children after DKA has occurred is brain edema,1 which is a rare complication of DKA, or hyperosmolar hyperglycemic syndrome, and has an estimated incidence of 0.03% and a poor outcome.2
Posterior reversible encephalopathy syndrome (PRES) is defined as a disorder of reversible subcortical brain edema in patients with typical neurological symptoms (e.g., visual loss, seizures, headache, and encephalopathy) which may be caused by chronic kidney disease, malignant hypertension, autoimmune disorders, and pre-eclampsia or eclampsia. Neuroimaging of patients with this condition usually shows vasogenic edema in the bilateral parieto-occipital regions.3
However, DKA-related PRES is rare. We report the first known case of PRES which developed after DKA occurred in a middle-aged woman.
A 44-year-old woman with a 1-day history of nausea and vomiting visited the emergency department of our hospital. She had type 2 diabetes, however, she did not comply with her recommended treatment plan. She reported no history of intravenous drug use, recent fever, or known recent contact with sick individuals. On examination, she was afebrile and had a blood pressure of 275/135 mmHg. The patient’s blood biochemistry test results were as follows: glucose level, 794 mg/dL; ketone level, 2.9 mmol/L, creatinine level, 6.4 mg/dL; and she had anion-gap acidosis with a pH of 7.29 and a HCO3− level of 17.4. She began to experience tonic-clonic seizures 1 hour after admission, and she began experiencing bilateral visual loss 2 hours later.
Moreover, she had severe delirium symptoms, including hallucinations. Brain computed tomography did not reveal intracranial hemorrhage or a low-density lesion. We performed brain magnetic resonance imaging (MRI) on the first day of admission, which revealed hyperintensity of the bilateral occipital and parietal cortexes on a fluid-attenuated inversion recovery T2 weighted image (Figure).
We administered adequate hydration and an insulin infusion of 30 U after breakfast and 15 U after dinner to lower her blood sugar levels and treat her ketoacidosis, after which her visual loss recovered on the third day after admission. Her delirium and seizure symptoms also began to improve progressively. We performed follow-up brain MRI on the thirteenth day after admission, which revealed that the patient had recovered completely. We diagnosed the patient with PRES. Before discharge, her blood sugar and hypertension had been brought under control, and her renal function had returned to normal. Moreover, her delirium and hallucination symptoms did not recur after one week had passed. At a follow-up visit 12 months after discharge, we were able to confirm that PRES did not recur.
PRES following the occurrence of DKA is a rare complication of diabetes mellitus in adults. According to existing reports, DKA induced PRES usually occurs in children.4–6 Our patient developed sudden seizures and visual loss along with hallucinations after admission and recovered soon after we reduced her blood sugar levels and treated her acidosis. Typical MRI changes in the brain when PRES occurs include hyperintensity of the bilateral occipital and parietal cortex, which occurred in our patient, who recovered in hospital on the thirteenth day after admission.
The underlying pathogenesis of PRES is not fully understood but it is thought to be caused by endothelial dysfunction or damage caused by excessive circulating inflammatory cytokines.3 However, the pathogenesis of DKA-induced PRES remains unclear. The common causes of PRES are chronic renal failure, autoimmune disease, malignant hypertension, preeclampsia or eclampsia, and immunosuppressants. DKA may induce PRES through an increase in serum proinflammatory cytokines, such as interleukins and TNF α, 7,8 which activate endothelial cells to produce vasoactive factors and enhance vascular permeability to provide the pathophysiological environment necessary for PRES to occur.
Brain edema in adult DKA usually has a poor outcome,2,9 as does PRES with hyperglycemia.10 However, after timely and adequate treatment of hyperglycemia and acidosis, our patient soon recovered without her symptoms recurring. We have reported the first case of DKA induced PRES in a middle-aged woman that we know of, and described typical symptoms and neuroimaging characteristics. Physicians should consider this condition as a possible complication of DKA that is treatable and has an excellent outcome.
PRES: Posterior Reversible Encephalopathy Syndrome
DKA: Diabetic Ketoacidosis
MRI: Magnetic Resonance Imaging
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All authors have no conflicts of interest to declare.
MKT drafted the manuscript.
CHL supervised the concept of the manuscript.
TJC critically reviewed the manuscript.
All authors approved the final draft of the manuscript submitted for publication.
We thank the staff of the Department of Medical Education and Research of the Taichung Armed Forces General Hospital for their assistance.