key: cord-0997090-tg9zexlx
authors: Donaldson, Laura; Margolin, Edward
title: Posterior Reversible Encephalopathy Syndrome in Acute COVID-19 Pneumonia
date: 2021-09-16
journal: Can J Neurol Sci
DOI: 10.1017/cjn.2021.221
sha: 3709c3b23b82481fb654c02c53b16f937276b456
doc_id: 997090
cord_uid: tg9zexlx

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In COVID-19, the mechanism of PRES is most likely related to the viral-induced cytokine storm. One likely effector is tumor necrosis factor-α (TNFα), a major inflammatory cytokine released primarily by macrophages but also by many other cell types to incite multiple downstream signaling cascades and induce effects such as increased vascular permeability. 2 Other cytokines such as interleukin-1 likely play a role and upregulate cell adhesion molecules including intercellular adhesion molecule-1 (ICAM1) and vascular cell adhesion protein-1 (VCAM1). 6, 7 An alternative hypothesis for the mechanism of PRES in these patients is dysregulation of the renin-angiotensin system (RAS) as SARS-CoV-2 spike protein binds to the angiotensin-converting enzyme-2 (ACE2) receptor to initiate cell entry. 8 This leads to ACE2 downregulation and downstream effects on the RAS, and bradykinin-kallikrein pathway may cause endothelial dysfunction and increased vascular permeability. 9 Drugs used to treat COVID-19 including hydroxychloroquine and tocilizumab may also be associated with PRES, 10, 11 though not a factor in this case.

PRES must be considered in COVID-19 patients with neurologic symptoms, particularly with severe bilateral vision loss. MRI of the brain with DWI is recommended in these cases to arrive at the correct diagnosis.

The authors have no conflicts of interest to declare.

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Axial MRI images showing extensive bilateral regions of increased signal on T2/FLAIR sequences (left panels parieto-occipital, right panels occipital) and high signal on apparent diffusion coefficient sequences (ADC) consistent with extensive vasogenic edema. Most regions showed T2 shine through on diffusion-weighted imaging with sparse patches of restricted diffusion. (B) Follow-up MRI images showing resolution of edema