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Posterior Reversible Encephalopathy Syndrome in a 13-Year-Old Female With Mild Systemic Lupus Erythematosus

A 13-year-old Hispanic girl with an 8-month history of systemic lupus erythematosus (SLE) presented with 3 episodes of new onset seizures. She had headache, fever, and sore throat 3 days prior to admission. She took acetaminophen orally and did not take decongestants or antitussives. The sore throat resolved but her headaches persisted. The patient denied vomiting, neck stiffness, joint pain, and visual disturbances. She had 3 episodes of seizure over a 6-hour period on the day of admission. A tongue bite was noted but no preceding focal signs or behavioral changes occurred during the first 2 seizures as witnessed by her mother. The third seizure had a focal onset with shaking in the right hand and then secondarily generalized. After the seizures she had elevated blood pressure for approximately 24 hours. She had been taking prednisone 20 mg, ranitidine 300 mg, naprosyn 750 mg, and hydroxychloroquine 200 mg daily. The patient was born in Ecuador and moved to the United States at the age of 7. She had pain in multiple joints starting 2 years prior to admission and was treated at another institution for a presumed diagnosis of polyarticular idiopathic arthritis. Eight months prior to admission, she presented to our clinic with arthritis, leukopenia, a strongly positive ANA, and positive DS DNA antibodies. Rheumatoid factor, SS-A antibodies, SS-B antibodies, and anti-phospholipid antibodies were negative. She was diagnosed with SLE and was treated with prednisone 20 mg and hydroxychloroquine 200 mg daily. She reported occasional mild headaches but otherwise her symptoms improved. Her family history was positive for arthritis and negative for seizures. All immunizations were up to date and she had no drug allergies. On examination, the patient was alert and oriented. Her height was 155 cm, weight was 44.5 kg, and body mass index was 19 kg/m. Temperature was 37.7°C, blood pressure was 147/73 mm Hg, heart rate was 105 beats per minute, and oxygen saturation was 100% while breathing ambient air. Neurological exam was normal. Meningeal signs were negative. There were papular lesions with necrotic centers on the buttocks and extensor surfaces of her elbows. The remainder of the physical exam was normal. The patient remained asymptomatic and her blood pressure stabilized to 107/62 mm Hg after being elevated for the first 24 hours after admission. Complete blood count, basic metabolic panel, and Mg were within normal limits except that glucose was 122 mg/dL. Urine toxicology was negative for barbiturates, benzodiazepines, cocaine, opiates, and methadone. Culture of the necrotic area of the rash was negative. Antibodies for HSV 1 and 2 and influenza A/B were not detected. Serum ANA was strongly positive (1:1280) and homogenous; C-reactive protein was elevated (139.57 mg/L); DS DNA, ribosomal P protein, and neuronal antibodies were negative; and C3, C4, and erythrocyte sedimentation rate and urinalysis were within normal limits. A noncontrast computed tomography (CT) scan showed no evidence of acute intracranial lesion. Cerebrospinal fluid (CSF) analysis revealed protein of 46.4 mg/dL and white blood cells (WBCs) of 7/mm3, 100% polymorphonucleocytes. CSF culture was negative. EEG showed a lack of normal background activity with voltage attenuation; there was no epileptiform activity. A total of 4 mg intravenous (i.v.) lorazepam and 750 mg of per os (PO) levetiracetam were given on hospital day 1. A maintenance dose of 250 mg PO levetiracetam was given twice a day starting on hospital day 2. Seizures did not recur. Magnetic resonance imaging (MRI) 2 days after admission showed broad areas of curvilinear horseshoe shaped