Authors: Dr Dayang suratun syafizah binti Dermawan , Dr Mohammad Fathullah bin Rossman , Dr Alia Farhana binti Mohammed Pisal

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a rare but treatable condition characterized by seizures, headache, altered mental status, and visual disturbances, often associated with hypertension. While increasingly recognized in adults, pediatric cases remain uncommon and diagnostically challenging. 

We report an 11-year-7-month-old, previously healthy, rugby-playing boy (60 kg) who presented with sudden onset of acute vision loss after waking up from afternoon nap. Early at school, he had a presyncopal episode, followed by persistent headache. He later vomited but did not have a fever . He experienced two generalized tonic-clonic seizures, the second with facial twitching which requiring IV diazepam. Notably, he had a year-long history of orthopnea, apnea, morning somnolence, and sneezing. On arrival he was confused with GCS E3V4M4 not oriented to time, place and person with BP 188/98 HR 115 and SpO2 92% under room air. On examination, there is reduced air entry bibasally with left-sided crepitations. Neurological examination revealed mild motor weakness, absent reflexes, and an asymmetrical Babinski sign.Both eyes had vision limited to hand movements, with normal fundoscopy finding. The patient developed a generalized tonic-clonic seizure and was subsequently intubated for cerebral and airway protection. Bedside ultrasound revealed bilateral pleural effusions, pulmonary edema, left ventricular enlargement, and a distended IVC. From imaging, CT brain showed hypodensity with white matter edema in the left parieto-occipital region of the posterior cerebral hemisphere.Chest X-ray shows increased vascular markings with a batwing appearance. He was loaded with IV phenytoin, and blood pressure was controlled with IV furosemide and nitrates. After stabilization he was transferred to tertiary centre for further management. 

This case underscores the diagnostic and management challenges of pediatric PRES. Although the syndrome is better understood overall, diagnosis in children remain limited. Due to few pediatric cases reported and their later onset compared to adults, clinicians often have limited experience with it. 

With limited literature and clinical exposure, PRES in the pediatric population is regarded as a novel clinicoradiological syndrome. Early recognition is crucial to prevent permanent neurological damage, reduce morbidity, and avoid mortality.

Keywords: Pediatric PRES, hypertension, pulmonary oedema