Rituximab-induced posterior reversible encephalopathy syndrome in a patient with systemic lupus erythematosus

Background. Posterior reversible encephalopathy syndrome (PRES) is a rare but serious neurological complication characterized by seizures, altered mental status, and imaging evidence of vasogenic edema. Although PRES has been reported in systemic lupus erythematosus (SLE), its association with rituximab is extremely rare, with fewer than 20 cases documented in the literature. Case presentation. A 23-year-old woman with class IV–V lupus nephritis, refractory to mycophenolate mofetil, was switched to rituximab to preserve fertility. After two intravenous doses, she developed generalized tonic-clonic seizures, altered sensorium, visual disturbances, and severe hypertension. MRI revealed vasogenic edema in the occipital, parietal, cerebellar, and brainstem regions. Infectious, metabolic, and autoimmune causes were excluded. Rituximab was discontinued, and the patient received antiepileptics, antihypertensives, corticosteroids, and hemodialysis. Neurological improvement occurred over 10 days. Diagnosis. Rituximab-induced PRES in a patient with active lupus nephritis. Treatment. Discontinuation of rituximab, seizure control, blood pressure management, corticosteroids, and renal support. Conclusion. PRES should be considered in SLE patients with neurological symptoms during biologic therapy. Early recognition and prompt imaging are essential.