Clinical characteristics, associated factors, and outcomes of posterior reversible encephalopathy syndrome in patients with systemic lupus erythematosus: a case-control study.

objectiveTo investigate the clinical characteristics, associated factors, and outcomes of posterior reversible encephalopathy syndrome (PRES) in patients with systemic lupus erythematosus (SLE).

methodsThis retrospective case-control study, conducted from 2009 to 2022, included 32 patients with SLE who developed PRES and 50 matched controls with neuropsychiatric SLE (NPSLE). Controls were matched for age, sex, and disease duration. Clinical characteristics, laboratory indices, neuroimaging findings, and treatment approaches were systematically evaluated. Multivariate logistic regression was performed to identify factors associated with PRES in patients with SLE. In addition, survival outcomes were compared according to different glucocorticoid (GC) dosing regimens.

resultsPatients with SLE who developed PRES had significantly longer hospitalizations and a higher frequency of hypertension compared with NPSLE controls (P < 0.05). Laboratory findings showed elevated white blood cell (WBC) and neutrophil (NE) counts, as well as increased levels of creatinine (Cr), blood urea nitrogen (BUN), and C-reactive protein (CRP); in contrast, serum albumin (Alb) and magnesium levels were markedly lower before the onset of neurological symptoms in the PRES group (all p < 0.05). PRES patients also demonstrated higher rates of nephritis and hypomagnesemia compared with NPSLE controls without PRES (p < 0.05). At the time of neurological symptom onset, seizures, visual impairment, and vomiting were more common in the PRES group, whereas acute confusional state were less frequent (p < 0.05). Neuroimaging revealed that patients with PRES more often exhibited lesions involving the parietal, occipital, frontal, and temporal lobes (p < 0.05). Multivariate logistic regression analysis identified several factors associated with an increased risk of PRES in patients with SLE: hypertension (OR 38.419, 95% CI: 6.073-243.037, p < 0.001), hypomagnesemia (OR 8.360, 95% CI: 1.542-45.322, p = 0.014), nephritis (OR 10.362, 95% CI:1.246-86.156, p = 0.030) and treatment with very-high-dose GC (OR 14.352, 95% CI: 1.927-106.921, p = 0.009). Furthermore, among SLE patients with PRES, survival rates differed significantly across GC dosing regimens (p = 0.045, Fisher's exact test), with rates of 50.00% (6/12) in the very-high-dose group, 88.24% (15/17) in the high-dose group, and 100.00% (3/3) in the low-medium-dose group. During follow-up (1-6 months), disease relapse occurred in three patients (9.38%).

conclusionHypertension, hypomagnesemia, nephritis, and the use of very-high-dose GC may represent potential factors associated with the development of PRES in patients with SLE. Moreover, treatment approaches, especially GC dosing, may influence patient survival outcomes.It should be emphasized, however, that the observed association involving hypomagnesemia, though statistically significant in this cohort, remains preliminary and necessitates further validation in larger, prospectively designed studies. Key Points • This study represents the largest case-control analysis of SLE-associated PRES to date (32 cases vs. 50 NPSLE controls), identifying multiple associated factors linked to PRES. • Hypomagnesemia and treatment with very-high-dose GCs were identified as novel associated factors for PRES in SLE, reported here for the first time. • Disease activity (SLE disease activity index (SLEDAI)) was compared between the SLE-PRES cohort (before and during the episode) and the NPSLE cohort. • Survival outcomes in SLE-PRES patients varied significantly according to GC dosing intensity (p = 0.045), with the highest mortality (50.0%) observed in the very-high-dose group.