Department of Nephrology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuokashimoaizuki Eiheiji-cho Yoshida-gun, Fukui, Japan.
Division of Neurology, Second Department of Internal Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan.
BMC Nephrol. 2023 Sep 29;24(1):286. doi: 10.1186/s12882-023-03319-7.
Endothelial dysfunction is common in patients undergoing chronic haemodialysis, and is a major cause of posterior reversible encephalopathy syndrome (PRES). Recently, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been shown to cause endothelial dysfunction by infecting vascular endothelial cells. Several cases of neurological complications in patients without kidney dysfunction, and only a few cases in patients with chronic kidney disease, have been reported in the literature. However, no previous report has yet described PRES associated with SARS-CoV-2 infection among patients undergoing maintenance dialysis.
A 54-year-old woman undergoing maintenance haemodialysis was admitted to our hospital for status epilepticus. She had developed end-stage kidney disease (ESKD) secondary to diabetic nephropathy. Seven days prior to admission, she had developed fever and was diagnosed with COVID-19. Subsequently her blood pressure increased from 160/90 mmHg to 190/100 mmHg. On admission, she presented with severe hypertension (> 220/150 mmHg), unconsciousness, and epilepticus. CT tomography revealed no signs of brain haemorrhage. Cranio-spinal fluid (CSF) examination revealed no signs of encephalitis, and CSF polymerase chain reaction (PCR) for SARS-CoV-2 was negative. MRI findings revealed focal T2/FLAIR hyperintensity in the bilateral parietooccipital regions, leading to the diagnosis of PRES. Deep sedation and strict blood pressure control resulted in a rapid improvement of her symptoms, and she was discharged without sequelae.
We report the first case of PRES associated with SARS-CoV-2 infection in a patient undergoing maintenance haemodialysis. Patients undergoing maintenance haemodialysis are at high risk of PRES because of several risk factors. SARS-CoV-2 infection causes direct invasion of endothelial cells by binding to angiotensin-converting enzyme 2 (ACE2), initiating cytokine release, and hypercoagulation, leading to vascular endothelial cell injury and increased vascular leakage. In the present case, SARS-CoV-2 infection possibly be associated with the development of PRES.
内皮功能障碍在接受慢性血液透析的患者中很常见，是后部可逆性脑病综合征（PRES）的主要原因。最近，严重急性呼吸综合征冠状病毒 2（SARS-CoV-2）已被证明通过感染血管内皮细胞导致内皮功能障碍。文献中报道了几例无肾功能障碍的患者出现神经系统并发症，以及少数慢性肾脏病患者出现神经系统并发症，但尚无先前的报告描述 SARS-CoV-2 感染与接受维持性透析的患者发生 PRES 相关。
一名 54 岁女性，因癫痫持续状态接受维持性血液透析，因糖尿病肾病继发终末期肾病（ESKD）。入院前 7 天，她出现发热并被诊断为 COVID-19。随后，她的血压从 160/90mmHg 升高至 190/100mmHg。入院时，她表现为严重高血压（>220/150mmHg）、意识不清和癫痫发作。CT 断层扫描未见脑出血迹象。脑脊液（CSF）检查未见脑炎迹象，CSF 聚合酶链反应（PCR）检测 SARS-CoV-2 为阴性。MRI 结果显示双侧顶枕叶局灶性 T2/FLAIR 高信号，提示 PRES。深度镇静和严格的血压控制使她的症状迅速改善，出院时没有后遗症。
我们报告了首例维持性血液透析患者 SARS-CoV-2 感染相关 PRES。由于多种危险因素，接受维持性血液透析的患者发生 PRES 的风险较高。SARS-CoV-2 感染通过与血管紧张素转换酶 2（ACE2）结合，引发细胞因子释放和高凝状态，导致血管内皮细胞损伤和血管通透性增加，从而直接侵犯内皮细胞。在本病例中，SARS-CoV-2 感染可能与 PRES 的发生有关。
