PRES From Sertraline Toxicity Presenting as a Hypertensive Emergency in Acute Liver Failure

First Author(s)

• 

  Justin Reinert, BCCCP, PharmD, MBA

  Critical Care Pharmacy Specialist
  n/a
  Toledo, Ohio

  Disclosure information not submitted.

  Slides and Audio

Co-Author(s)

• RL

  Rachel Leis, Pharm.D., BCPS, BCCCP

  Critical Care Pharmacy Specialist
  Bon Secours Mercy Health St. Vincent Medical Center, United States

  Disclosure information not submitted.
• AP

  ALISON PAPLASKAS, PharmD, BCCCP

  Emergency Medicine Pharmacy Specialist
  Detroit Medical Center, United States

  Disclosure information not submitted.

Title: PRES from sertraline toxicity presenting as a hypertensive emergency in acute liver failure
Case Report Body:

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a clinical situation which occurs as a result of impaired autoregulatory functions of the brain with regard to cerebral blood flow, most commonly associated with uncontrolled hypertension. Serotonin syndrome presenting with significantly elevated blood pressure may lead to PRES.

Description: We describe a 63-year-old Caucasian female who presented to the ED at an outlying affiliated hospital with complaints of altered mental status and who was classified as a stroke alert. Her blood pressure on admission was 258/112 mmHg. Pertinent past medical history included hypertension managed with lisinopril 5 mg daily, depression managed with sertraline 200 mg daily, and dialysis-dependent chronic kidney disease. The patient was found to be in acute liver failure with LFT’s greater than 5 times the upper normal limit and an ammonia level of 348 mmol/L. The patient was transferred to our tertiary care center for medical management and admitted to the neurointensive critical care unit. Upon arrival, a CT scan and MRI independently confirmed a diagnosis of PRES based on visualizing subcortical areas of hypoattenuation. The patient’s sertraline doses were held, and an aggressive antihypertensive regimen including a clevidipine infusion and multiple bolus doses of hydralazine and labetalol were effective in drastically improving the patient’s symptoms. The patient’s liver function returned to baseline within 72 hours and the patient was ultimately discharged to home in stable condition.

Discussion: This patient’s acute liver failure was the precipitating factor in this unique presentation of PRES. Sertraline undergoes extensive hepatic metabolism and requires dose adjustment or avoidance in patients with hepatic insufficiency as defined by the Child-Turcotte-Pugh (CTP) classification system. Our patient qualified as CTP Class B upon arrival, thereby indicating that sertraline should have been avoided and lending credence to the notion that sertraline toxicity led to a pseudo-serotonin syndrome presenting as a hypertensive emergency leading to PRES. Despite the presence of hyperammonemia, the resolution of symptoms with antihypertensive therapy and the holding of sertraline doses supports our description of the uncommon etiology witnessed in this case of PRES.