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 Table of Contents  
Year : 2017  |  Volume : 12  |  Issue : 1  |  Page : 126-127

Authors' reply

1 Department of Neurology, Tuticorin Medical College, Thoothukudi, Tamil Nadu, India
2 Department of Medicine, Sundaram Arulrhaj Hospitals, Tuticorin, Tamil Nadu, India
3 Department of Neurology, Appusami Hospital, Salem, Tamil Nadu, India

Date of Submission05-Oct-2016
Date of Acceptance06-Nov-2016
Date of Web Publication15-Feb-2017

Correspondence Address:
E Prasanna Venkatesan
3, Vijayarahavachari Road, Gandhi Road, Salem 636 007, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2008-322X.200165

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How to cite this article:
Ramakrishnan S, Kannan B, Kannan A, Venkatesan E P. Authors' reply. J Ophthalmic Vis Res 2017;12:126-7

How to cite this URL:
Ramakrishnan S, Kannan B, Kannan A, Venkatesan E P. Authors' reply. J Ophthalmic Vis Res [serial online] 2017 [cited 2017 Nov 20];12:126-7. Available from: http://www.jovr.org/text.asp?2017/12/1/126/200165

Dear Editor,

Hemodynamic dysregulation due to autonomic nerves involvement is common in Guillain-Barre syndrome (GBS). About 61% of patients suffering from GBS have transient hypertension and 43% have postural hypertension.[1] Persistent hypertension is not a prerequisite for posterior reversible encephalopathy syndrome (PRES) and 15 to 20% of subjects with PRES are normotensive or hypotensive.[2] Transient hypertension is sufficient to disrupt the autoregulation and lead to PRES. Moreover, the upper limit for autoregulation varies between different individuals. Our patient did not have persistent hypertension, but could have had transient hypertension.

In the literature, there are 5 case reports of PRES following IVIG. Mathy et al reported PRES on the first day of IVIG, and Voltz et al described PRES after 3 days of IVIG. Doss-Esper et al reported PRES and reversible cerebral vasoconstriction syndrome leading to stroke after one day administration of IVIG, Koichihara et al described PRES in a 14-year-old girl 3 days after IVIG, and Faruk Incecik et al reported PRES after 5 days of IVIG. Actually, all patients developed PRES within 5 days of IVIG treatment. Although these patients were diagnosed to develop PRES related to IVIG, transient autonomic disturbance secondary to GBS could also have contributed to PRES.[3],[4],[5],[6],[7] In the study conducted by Doss-Esper et al, the patient developed acute hypertension after IVIG. Our patient developed PRES following 10 days of IVIG treatment which makes it an improbable cause for PRES. PRES has been reported to be associated with other autoimmune diseases, such as neuromyelitis optica spectrum disorders, autoimmune thyroid disease and systemic lupus erythematosus.[8],[9],[10] Further research is required to explain the occurrence of PRES with GBS and other autoimmune disorders.

Based on just few case reports, we would not conclude that PRES precedes GBS. We believe PRES can either precede or occur during the course of GBS. GBS with dysautonomia can be considered as an independent risk factor for PRES.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Lichtenfield P. Autonomic dysfunction in the Guillain–Barré syndrome. Am J Med 1971;326:1130-1136.  Back to cited text no. 1
Rabinstein AA, Mandrekar J, Merrell R, Kozak OS, Durosaro O, Fugate JE. Blood pressure fluctuations in posterior reversible encephalopathy syndrome. J Stroke Cerebrovasc Dis 2012;21:254-258.  Back to cited text no. 2
Mathy I, Gille M, Van Raemdonck F, Delbecq J, Depré A. Neurological complications of intravenous immunoglobulin (IVIg) therapy: An illustrative case of acute encephalopathy following IVIg therapy and a review of the literature. Acta Neurol Belg 1998;98:347-355.  Back to cited text no. 3
Voltz R, Rosen FV, Yousry T, Beck J, Hohlfeld R. Reversible encephalopathy with cerebral vasospasm in a Guillain-Barre syndrome patient treated with intravenous immunoglobulin. Neurology 1996;46:250-251.  Back to cited text no. 4
Doss-Esper CE, Singhal AB, Smith MS, Henderson GV. Reversible posterior leukoencephalopathy, cerebral vasoconstriction, and strokes after intravenous immune globulin therapy in Guillain-Barr'e syndrome. J Neuroimaging 2005;15:188-192.  Back to cited text no. 5
Koichihara R, Hamano S, Yamashita S, Tanaka M. Posterior reversible encephalopathy syndrome associated with IVIG in a patient with Guillain-Barré syndrome. Pediatr Neurol 2008;39:123-125.  Back to cited text no. 6
Incecik F, Hergüner MO, Altunbasak S, Yıldızdas D. Reversible posterior encephalopathy syndrome due to intravenous immunoglobulin in a child with Guillain-Barré syndrome. J Pediatr Neurosci 2011;6:138-140.  Back to cited text no. 7
Magaña SM, Matiello M, Pittock SJ, McKeon A, Lennon VA, Rabinstein AA, et al. Posterior reversible encephalopathy syndrome in neuromyelitis optica spectrum disorders. Neurology 2009;72:712-717.  Back to cited text no. 8
Tateishi Y, Iguchi Y, Kimura K, Aoki J, Uemura J, Shibazaki K. A case of autoimmune thyroid disease presenting posterior reversible encephalopathy syndrome. J Neurol Sci 2008;271:203-206.  Back to cited text no. 9
Leroux G, Sellam J, Costedoat-Chalumeau N, Le Thi Huong D, Combes A, Tieulié N, et al. Posterior reversible encephalopathy syndrome during systemic lupus erythematosus: Four new cases and review of the literature. Lupus 2008;17:139-147.  Back to cited text no. 10


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