Purpose or Case Report: Neuropsychiatric symptoms are common manifestations of lupus, often presenting within a year of diagnosis. The American College of Rheumatology (ACR) published a list of 19 neuropsychiatric syndromes observed in SLE citing an up to 20% incidence of generalized or focal seizures. PRES, which typically presents with seizures, headache, altered mental status and visual disturbances, may mimic neuropsychiatric SLE (NPSLE), as presented in this case.

The patient is a 17-year-old female with a history of SLE (diagnosed 2 months prior), lupus nephritis (class IV), GAD, and prior suicide attempt who presented via EMS after an unwitnessed fall. En route to the hospital, she had a seizure which lasted less than 5 minutes. In the ED, she was hypertensive to 146/92 mmHg and physical exam was notable for dilated but reactive pupils and GCS 11. While undergoing a CT scan of the head, she had 2 more seizures. CT scan revealed no acute abnormalities. She was medically stabilized and subsequently transferred to the PICU for further management. Blood pressure had increased to 162/106 mmHg. MRI brain and MRA Head and Neck were obtained which revealed findings most consistent with PRES without any evidence of vasculitis or high-grade stenosis.

Hospital course was complicated by ARDS secondary to pulmonary hemorrhage requiring intubation, increased PTT, MRSA and C Diff infections, for which the patient was treated. 24-hour vEEG did not reveal any seizure activity but showed diffuse slowing of brain waves suggestive of gross cerebral dysfunction. Repeat MRI 5 days after admission showed no changes in above described MRI findings. Patient’s blood pressure improved to 146/92, but she remained intubated and sedated due to ARDS, making it difficult to assess for any improvement in her mental status. Patient was subsequently transferred to an ECMO-capable hospital due to profound hypoxia.

PRES, which often presents with seizures, has been described as a presenting feature of SLE in case reports, and can mimic NPSLE. The underlying pathophysiology and management of NPSLE and PRES are distinct, therefore identifying the imaging features of the many presentations of NPSLE and the imaging findings of PRES is imperative. PRES typically has a favorable outcome if recognized and treated promptly. We present a case of PRES in newly-diagnosed SLE to highlight the imaging features and importance of blood pressure monitoring in early SLE.
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