Merciai F, Pagano T, Petrosino M, Erra A, Scarano D, Muoio R, Carbone D. Fulminant postpartum posterior reversible encephalopathy syndrome associated with hemolysis, elevated liver enzymes, and low platelet count syndrome: A case report. World J Anesthesiol 2026; 14(1): 123553 [DOI: 10.5313/wja.123553]
Corresponding Author of This Article
Federica Merciai, MD, Department of Anesthesia and Intensive Care, "Umberto I" Hospital, St. Alfonso De Nicola, Nocera Inferiore 84014, Campania, Italy. federica.merciai@hotmail.it
Research Domain of This Article
Anesthesiology
Article-Type of This Article
case-report
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World J Anesthesiol. Sep 22, 2026; 14(1): 123553 Published online Sep 22, 2026. doi: 10.5313/wja.123553
Fulminant postpartum posterior reversible encephalopathy syndrome associated with hemolysis, elevated liver enzymes, and low platelet count syndrome: A case report
Federica Merciai, Tommaso Pagano, Massimo Petrosino, Aniello Erra, Daniele Scarano, Raffaele Muoio, Domenico Carbone, Department of Anesthesia and Intensive Care, "Umberto I" Hospital, Nocera Inferiore 84014, Campania, Italy
Author contributions: Merciai F and Pagano T contributed to the manuscript's writing and editing, and to data analysis; Petrosino M and Erra A contributed to the data collection; Scarano D, Muoio R, and Carbone D contributed to the study's conceptualization and supervision; and all authors read and approved the final manuscript.
AI contribution statement: The authors declare that no AI tools were used for this manuscript and take full responsibility for the accuracy of the review, confidentiality of the manuscript, and ethical integrity of this case report.
Informed consent statement: An informed consent was obtained for the publication of this case.
Conflict-of-interest statement: The authors have no conflict of interest to declare.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: Federica Merciai, MD, Department of Anesthesia and Intensive Care, "Umberto I" Hospital, St. Alfonso De Nicola, Nocera Inferiore 84014, Campania, Italy. federica.merciai@hotmail.it
Received: June 9, 2026 Revised: July 15, 2026 Accepted: August 10, 2026 Published online: September 22, 2026 Processing time: 105 Days and 18 Hours
Abstract
BACKGROUND
Posterior reversible encephalopathy syndrome (PRES) is a neuroradiological condition commonly associated with hypertensive disorders of pregnancy, including preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Although PRES is generally considered reversible after prompt treatment, atypical and hemorrhagic variants may rapidly progress toward irreversible neurological injury and death.
CASE SUMMARY
A 33-year-old woman at 37 weeks of gestation was admitted with severe hypertension, headache, and abdominal pain. Laboratory findings were consistent with HELLP syndrome, prompting urgent cesarean delivery. Shortly after surgery, the patient developed recurrent visual disturbances, cortical blindness, confusion, and generalized seizures. Brain magnetic resonance imaging demonstrated extensive bilateral cortico-subcortical hyperintensities involving the parieto-occipital regions, basal ganglia, posterior cingulate cortex, pons, cerebellum, and splenium of the corpus callosum, consistent with atypical PRES. The patient developed hemorrhagic transformation, diffuse cerebral edema and then brain death, despite the early intensive treatment by magnesium sulfate, antihypertensive therapy, mechanical ventilation, antiepileptic treatment, osmotherapy and platelet transfusion.
CONCLUSION
Hemorrhagic central PRES associated with HELLP syndrome may rapidly evolve toward fatal neurological injury despite early diagnosis and treatment.
Core Tip: This report describes a rare and catastrophic postpartum case of posterior reversible encephalopathy syndrome (PRES) associated with hemolysis, elevated liver enzymes, and low platelet count syndrome and eclampsia complicated by hemorrhagic transformation, diffuse cerebral edema, and brain death. The case highlights that PRES is not invariably reversible and emphasizes the prognostic role of atypical magnetic resonance imaging findings, intracranial hemorrhage, and severe endothelial dysfunction.
