Posterior Reversible Encephalopathy Syndrome (PRES) Associated with Profound Vitamin C Deficiency
Objective:
Describe a case of posterior reversible encephalopathy syndrome (PRES) associated with profound vitamin C deficiency.
Background:
An association between vitamin C deficiency and PRES has not been previously described and warrants further study as a potential additional risk factor and target for treatment of PRES.
PRES is an acute neurological disorder characterized by reversible vasogenic cerebral edema with a predilection for posterior subcortical parieto-occipital regions. It is hypothesized to occur due disrupted cerebrovascular autoregulation and endothelial dysfunction. Diagnosis is made based on a combination of acute neurological symptoms, focal vasogenic edema on neuroimaging (typically MRI), and clinical or radiologic reversibility.
Vitamin C plays a role in cardiovascular health due pleiotropic effects on collagen synthesis, antioxidation and nitric oxide bioavailability/function. Vitamin C supplementation reduces biomarkers of inflammation and endothelial injury. Meta analyses demonstrate significant improvements in endothelial function with vitamin C supplementation with a dose-response relation in patients with endothelial dysfunction. In addition, vitamin C stimulates hypoxia-inducible family oxidases and prevents downstream endothelial dysfunction and pulmonary hypertension.
Design/Methods:
Case report.
Results:
A woman in her 70s with hypertension and renovascular disease presented with PRES in the setting of profound vitamin C deficiency. The patient presented with a generalized tonic-clonic seizure and hypertensive emergency. Imaging revealed vasogenic edema in bilateral, predominantly posterior cerebral and cerebellar regions. Concurrently, signs of scurvy including halitosis, oral bleeding, and petechiae were noted and ascorbic acid returned undetectable. The patient was treated with antihypertensives and vitamin C repletion with rapid return to neurological baseline and no neurological sequelae on follow-up.
Conclusions:
Vitamin C deficiency is associated with endothelial dysfunction. This case raises the possibility of an association between vitamin C deficiency and PRES and underscores the need for further research into this relationship and its potential implications for management strategies in critically ill patients.
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