Posterior reversible encephalopathy syndrome precipitated by alcohol withdrawal: Case report and review of the literature

A 55-year-old male without medical co-morbidities was referred to our hospital after presenting to an acute care clinic with confusion. No medical history could be obtained from the patient initially. Collateral history from his wife revealed the patient had a history of alcohol use disorder, and regularly drank at least four cans of beer a night for decades. He had abruptly ceased drinking three days prior to presentation. His wife described him as more irritable, and verbally aggressive, and that he was disoriented on the day of presentation. There was no mention of psychotic symptoms, abnormal speech, or observed seizure activity. He did not take any medications regularly, and was a distant ex-smoker. His wife denied any knowledge of previous hypertension diagnosis, or illicit drug use. Examination at the time of his admission revealed tachycardia (108 bpm) and hypertension (185/103 mmHg). The patient was cachectic, and although alert, he was disoriented to time and place. His neurological examination was only remarkable for an ataxic gait. An electro-cardiogram on admission showed a sinus rhythm without voltage evidence of left ventricular hypertrophy. Basic blood tests revealed normal full blood count, renal function, thyroid function tests, and B12/folate. His liver functions tests were only notable for a raised GGT (205 U/L; reference range 10–50), and his fasting ammonia level was only mildly raised (46 μmol/L; reference range 11–32). Blood alcohol levels and urinary toxicology screen were not undertaken. At the time of his admission, he had a normal non-contrast CT brain (see Fig. 1A). The patient was commenced on thiamine and vitamin B-complex replacement, as well as Diazepam (in accordance with our Alcohol Withdrawal Scale protocol). On the following morning, the patient had some improvement in his mental state, and was able to interact with the medical team during their rounds. He confirmed that his last drink was three days prior to presentation. The medical team noted bilateral dysmetria of the upper limbs, a rest tremor of the right hand, and an ataxic, broad-based gait. On day 2 of his admission, the patient had three generalised tonic–clonic seizures (GTCS) in the space of two hours. The second and third seizures necessitated intravenous Midazolam to terminate. He was commenced on twice-daily intravenous Levetiracetam 500 mg, and the team requested a repeat non-contrast CT brain; this showed new bilateral occipito-parietal and equivocal cerebellar abnormalities (see Fig. 1B–D), raising suspicion for posterior reversible encephalopathy syndrome (PRES). As he remained hypertensive (BP range 140–205/80–108 mmHg), he was commenced on several anti-hypertensives. The neurology team was then consulted. At this time, the patient was disoriented, and could not follow one-step ⁎ Corresponding author at: Canterbury District Health Board, 2 Riccarton Avenue, Christchurch 8011, New Zealand. E-mail address: yassar.alamri@nzbri.org. NEUROLOGY PERSPECTIVES