A Case of Spastic Quadriplegia Remaining after Multiple Traumatic Injuries Complicated by Sepsis and Reversible Posterior Leukoencephalopathy Syndrome, as well as Delayed Multifocal Microbleeds

To the Editor, A 43-year-old woman with bipolar disorder and a medication overdose was found unconscious on the premises of her condominium. She was comatose and was in a state of shock when she found. No significant external injuries were observed based on her clothing; however, owing to her history, acute drug poisoning was suspected, and she was transported to our hospital. On arrival, her Glasgow Coma Scale score was 3, and a physical examination revealed the following: blood pressure – 44/22 mmHg; heart rate – 116 beats/min; and respiratory rate – 24 breaths/min. Immediate endotracheal intubation was performed. Emergency blood transfusion and fluid resuscitation were performed because of anemia detected on a blood gas analysis. Urine screening was positive for benzodiazepines. Our hospital routinely conducts a whole-body computed tomography (CT) scan in cases of acute drug poisoning. This revealed brain contusions, multiple rib, sternum, and L2 vertebra fractures, open pelvic fractures, chest aortic, liver, and kidney injuries, as well as right hemothorax and pulmonary contusions. Massive transfusion, management of hepatic injury, and embolization of the internal iliac artery branches were performed on the day of admission. On day 4, stent graft insertion was performed for the chest aortic injury, and open pelvic fixation was performed on day 19. Complications included pelvic infection, bile leakage, and empyema. Despite controlling the infection with antibiotics, the patient experienced prolonged consciousness impairment. Initially, only brain contusions were observed on CT, but follow-up head magnetic resonance imaging revealed multiple delayed microbleeds and reversible posterior encephalopathy syndrome (PRES) [Figure 1]. The diagnostic criteria for disseminated intravascular coagulation, collagen disease, and vasculitis markers were negative, and it was inferred that PRES and delayed microbleeds occurred because of increased vascular permeability and vasculitis associated with sepsis. Subsequently, the patient regained consciousness but had residual spastic quadriplegia due to bilateral pyramidal tract damage, rendering her unable to walk. She was subsequently transferred to another facility.Figure 1: Series of head magnetic resonance imaging (MRI) scans (Upper row - day 42; Middle row - day 74; and Lower - row 95). MRI on day 74 showed delayed microbleeds in the white matter. MRI on day 95 showed improvement of the bilateral areas of high intensity in the white matter in the parieto-occipital regions, which was diagnosed as reversible posterior leukoencephalopathy syndromeThe present case was a unique occurrence involving combined PRES with sepsis following multiple traumas and delayed multiple small hemorrhages, resulting in spastic quadriplegia. To our knowledge, there have been no previous reports of the combination of PRES and multiple small cerebral hemorrhages, making this the first documented case of its kind. PRES has been vastly underrecognized in previously reported cohorts of patients with sepsis and septic-associated encephalopathy.[1] Microbleeds can be associated with indices of brain endothelium activation, blood–brain barrier disruption, and neuroinflammation induced by sepsis. The prolonged septic state induced by gluteus pus, biloma, and pyothorax in the present case may have been associated with the occurrence of delayed multiple microbleeds in the patient's brain.[2] Accordingly, when consciousness impairment persists after sepsis, consideration should be given to the sequelae, including PRES and cerebral microbleeds. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship This work was supported in part by a grant-in-aid for special research in subsidies for ordinary expenses of private schools from the promotion and mutual aid corporation for private schools of Japan. Conflicts of interest There are no conflicts of interest.