Posterior Reversible Encephalopathy Syndrome With Spinal Cord Lesions Associated With Malignant Hypertension and Post-renal Transplantation Rejection in a Patient With IgA Nephropathy: A Case Report

A 40-year-old Japanese male patient was admitted to the emergency room because he had been experiencing visual disturbances in both eyes for a month, and his fatigue had worsened over the past week. He was diagnosed with IgA nephropathy 24 years ago and underwent a living donor kidney transplant 19 years ago. The patient was administered tacrolimus and mycophenolate mofetil (MMF) since the renal transplantation. Upon admission, his blood pressure (BP) rose to 250/150 mmHg. Neurological examination revealed bilateral light perception, left homonymous hemianopsia, bilateral patellar hyperreflexia, and decreased sensation of vibration below the lumbar region. Brain magnetic resonance imaging (MRI) showed hyperintense areas on both fluid-attenuated inversion recovery (FLAIR) and apparent diffusion coefficient (ADC) maps in the right parieto-occipital lobe, left basal ganglia, and white matter around the lateral ventricles, brainstem, and bilateral cerebellar hemispheres. Some lesions showed hyperintense areas on the diffusion-weighted image (DWI). MRI of the spinal cord on T2-weighted images showed hyperintense areas in the center of the entire spinal cord. The patient was diagnosed with posterior reversible encephalopathy syndrome with spinal cord involvement (PRES-SCI) and was treated with antihypertensive therapy, immunosuppressive drugs, and dialysis. The patient's clinical symptoms and imaging findings gradually improved. A follow-up MRI of the brain and spinal cord on day 43 after onset showed almost complete disappearance of the lesions. This is the first reported case of PRES-SCI involving the entire spinal cord in a patient with renal disease. In this case, malignant hypertension, post-transplantation rejection, and immunosuppressive medications may have been involved in the onset of PRES-SCI. Prompt diagnosis and treatment may lead to favorable outcomes.