Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

SEVERE HYPERTENSIVE URGENCY AND POSTERIOR REVERSIVE ENCEPHALOPATHY SYNDROME IN THE SETTING OF CHRONIC OPIOID WITHDRAWAL: A DIAGNOSTIC AND MANAGEMENT CHALLENGE Gabrielle Aluisio 1 , MBA, OMS-III, Lindsey Saleski 1 , DO, MBA 1. Edward Via College of Osteopathic Medicine – Carolinas Campus Introduction Case

Discussion/Conclusion

Posterior reversible encephalopathy syndrome (PRES) presents with altered mentation, drowsiness, seizures, and sudden non localized headaches 1,2 Patients usually have 1 or more risk factors such as hypertension, kidney disease, exposure to cytotoxic medication 1,2 There are three main proposed mechanisms: 2-4 - Dysregulation of cerebral autoregulation: When systolic is >160, the amount of vasoconstriction is maximized, and blood flow rises with increasing BP leading to a BBB breakdown and intravascular fluid leakage into posterior circulation - Endothelial dysfunction: normotensive patients on cytotoxic therapies that disrupt BBB leading to capillary leakage and axonal swelling triggering vasogenic edema - Cerebral ischemia: disordered autoregulation leading to focal vasoconstriction and hypoperfusion, cytotoxic edema, and cerebral infarction 58-year-old female presents to the emergency department with severe, diffuse flank and low back pain and confusion Patient is prescribed morphine 45mg BID for chronic back pain. She has not taken the medication since yesterday morning. Patient reports that she woke up from a nap disoriented and is unable to correctly identify day, month, or time. Unable to perform ROS due to mental status change. Vitals : BP 143/115 , Temp 97.9 ℉ , Pulse 94,RR 18 Clinical Opiate Withdrawal Scale > 30 suggestive of moderately severe opiate withdrawal. Patient was given 16 mg buprenorphine and placed on oxygen due to respiratory acidosis Case

• This case of PRES highlights the diagnostic challenges and broad differential diagnoses required to properly rule out other causes of non-specific neurological symptoms such as altered mental status and seizures. • While hypertension is a known trigger for PRES, the co occurrence with opioid withdrawal is rarely documented. • This case required multimodal management including seizure control, blood pressure control, and symptomatic treatment for withdrawal, contrasting with traditional cases where antihypertensives alone suffice • PRES is associated with vasogenic edema with lesions showing high signal intensity on FLAIR and elevated ADC values, compared to an acute ischemic stroke which is associated with cytotoxic edema, high signal intensity on DWI and lower ADC values 5,6 • Stimulation of opioid receptors may reduce arterial hypertension, whereas long-term dependence leads to hypertension 7-9 • Data on opioid withdrawal induced blood pressure alterations are limited, therefore this case may highlight the importance for further studies to elucidate the risk factors for PRES • This case highlights the need to consider PRES in patients with atypical presentations and to tailor treatment to address underlying causes effectively.

Patient remained altered and sedated following treatment and started hallucinating Vitals : BP 163/86 , HR 82, RR 18, Temp 98.2 ℉ The Urine Drug Screen was positive for opioids. The MRI, CT, lumbar puncture, and viral panel were all negative, ruling out common causes of encephalopathy.

A repeat head CT W/O contrast found increased hypoattenuation within the lobes bilaterally, worrisome for PRES (Figure 1) Vitals : BP 178/97 , Temp 101.5 ℉ , HR 75 Patient displayed tonic-clonic seizure like activity followed by presumed postictal state. Patient continued to be combative and agitated. Patient was given Haldol 5 mg IM q8 prn, however, remained mildly confused

Figure 1. CT with increased hypoattenuation in posterior lobes

Subsequent MRI was done to confirm diagnosis which showed findings indicative of PRES. Neurology recommended patient remain on lacosamide for 6 months and follow up for repeat MRI in 2-3 weeks (Figure 2)

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References

Figure 2. MRI A) while in hospital B) 3 weeks later as outpatient

2025 Research Recognition Day

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