Case Presentation: A 46-year-old woman with iron deficiency anemia presented with headache, right hand weakness, and “difficulty texting and folding clothes,” two weeks after being hospitalized for symptomatic anemia with shortness of breath and hemoglobin of 2.9 g/dL. During her previous admission, she received transfusions of 3 units of red blood cells and was discharged home with a hemoglobin level of 7.5 g/dl. She now presented to the emergency department with 3-days of constant, non-localized headache and 1-day history of clumsiness and weakness of the right hand. On physical exam her blood pressure was 179/78 mmHg, and there was numbness, reduced dexterity and apraxia of her right hand. Routine labs were unremarkable and her hemoglobin was 7.5 g/dl. An MRI of the brain showed multiple subcortical high-intensity lesions on bilateral anterior, parietal, and occipital lobes on T2-FLAIR images. On lumbar puncture, the CSF analysis was unremarkable. Pregnancy test, hypercoagulable work-up, RF, ANA, and ANCA were negative. The hospital course was complicated by a brief episode of tonic convulsive seizure which self-resolved. Given her neurologic symptoms and radiologic findings, the clinical diagnosis of Posterior Reversible Encephalopathy Syndrome (PRES) secondary to blood transfusion was made. Her headache and neurological symptoms of the right hand gradually improved after starting oral calcium channel blocker. A follow–up MRI 4 weeks after discharge showed resolution of the high-intensity lesions.
Discussion: PRES is a neurologic syndrome characterized by acute onset of headache, altered mental status, seizure, and visual disturbances, with radiographic findings of symmetrical white matter edema in the posterior cerebral hemispheres, particularly in the parieto-occipital regions. A number of medical conditions are known as causes of PRES, which include hypertensive encephalopathy, eclampsia, vasculitis, and the use of cytotoxic drugs. Rapid correction of anemia with transfusion is a rare cause of PRES with only 10 cases described in literature as of April 2016, according to Cevallos CA and Berman BS. The pathogenesis of PRES after transfusion remains unclear, but it has been proposed that a rapid rise in the hematocrit results in both increased blood viscosity and a loss of hypoxic vasodilation, leading to disordered cerebral autoregulation and endothelial dysfunction. Most of the cases develop from several days to two weeks after transfusion, and more likely to occur when the chronic anemia is rapidly corrected. Moderate hypertension as seen in this patient has been described as a complication of PRES. The prognosis is mostly benign and PRES is fully reversible within days to weeks, after removal of the inciting factor (rapid correction of hematocrit in this case) and blood pressure control with vasodilator if hypertensive.
Conclusions: Physicians should have a high index of suspicion for this rare but serious condition if a patient with chronic anemia develops neurological symptoms after RBC transfusion, and should avoid rapid correction of chronic anemia without hemodynamic instability.
To cite this abstract:Mitaka, H; Seijo, L; Motohashi, K; Nakai, M; Burger, A. A SERIOUS ADVERSE EVENT OF RED BLOOD CELL TRANSFUSION: A CASE OF POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME (PRES). Abstract published at Hospital Medicine 2019, March 24-27, National Harbor, Md. Abstract 856. https://www.shmabstracts.com/abstract/a-serious-adverse-event-of-red-blood-cell-transfusion-a-case-of-posterior-reversible-encephalopathy-syndrome-pres/. Accessed April 9, 2020.