Posterior Reversible Encephalopathy Syndrome (PRES) following gastrointestinal sepsis in a child: a case report

Abstract

Posterior Reversible Encephalopathy Syndrome (PRES) is a rare neurological entity in the paediatric population, whose diagnosis relies primarily on brain MRI. Although at-risk populations are well established, cases occurring in the context of sepsis of gastrointestinal origin are rare, particularly in paediatric intensive care settings in sub-Saharan Africa. Case presentationA 12-year-old girl with no medical history was admitted for peritonitis secondary to ileal perforation, managed after a two-week delay. The initial presentation combined severe sepsis, grade 2 arterial hypertension, acute kidney injury, severe hypoglycaemia and metabolic acidosis. Postoperatively, two haemodialysis sessions corrected renal function and resolved the choreiform movements and bruxism, whereas arterial hypertension and agitation persisted. On the tenth postoperative day, the onset of refractory seizures and bilateral cortical blindness prompted brain MRI, which revealed bilateral symmetrical parieto-occipital vasogenic oedema — involving the medial occipital lobes and the calcarine cortex — with cerebellar involvement and haemorrhagic stigmata on susceptibility-weighted sequences, confirming the diagnosis of PRES. Intravenous nicardipine and levetiracetam were initiated. The outcome was favourable, with complete neurological recovery and full visual restitution after 65 days. This case illustrates the diagnostic complexity of PRES in paediatric intensive care within a resource-limited setting. It suggests that sepsis of gastrointestinal origin may contribute to the occurrence of PRES both directly and by initiating associated dysfunctions — arterial hypertension, acute kidney injury, hypovolaemia and uraemic encephalopathy — acting as contributory cofactors. The diagnosis of PRES was retained as predominant on the basis of brain imaging and clinical reversibility under treatment. Finally, this case underscores that the timeliness of diagnosis and management of the triggering factor — peritonitis — is an essential determinant of neurological outcome. • PRES should be considered in any acute neurological presentation occurring in a septic context, including in paediatric patients. • Sepsis of gastrointestinal origin, although rarely reported, may act as a triggering factor for PRES, both directly through the systemic inflammatory response and indirectly by initiating associated dysfunctions — arterial hypertension, acute kidney injury, hypovolaemia and uraemic encephalopathy. • The persistence of neurological signs despite correction of metabolic disorders and renal function should prompt reconsideration of a metabolic encephalopathy diagnosis and lead to brain MRI. • Involvement of the calcarine cortex and medial occipital lobes (structures classically spared in PRES) accounts for cortical blindness and may be associated with prolonged visual recovery. • Timeliness of diagnosis and management of the triggering factor is an essential determinant of neurological outcome, including in resource-limited settings where access to MRI remains constrained.