Septic shock — MCCQE Part 1 MCQ

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HardAltered Level of ConsciousnessSeptic shockMCCQE Part 1

A patient receiving tacrolimus develops headache, confusion, visual loss and seizures with blood pressure 210/120 mm Hg. MRI shows bilateral posterior vasogenic edema. What is the best management?

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Correct answer: D — Control seizures and pressure while removing the trigger

Acute encephalopathy, visual symptoms, seizures, severe hypertension and posterior vasogenic edema indicate posterior reversible encephalopathy syndrome. Admit to monitored care, treat seizures, lower blood pressure with a titratable intravenous agent in a controlled fashion and stop or reduce the offending calcineurin inhibitor with transplant-specialist input. Rapid normalization can cause cerebral ischemia, while untreated pressure promotes hemorrhage and edema. Evaluate kidney function, eclampsia, autoimmune disease and other triggers. PRES is often reversible with early treatment but can cause infarction, hemorrhage or status epilepticus when management is delayed.

Reference: NIH—Posterior Reversible Encephalopathy Syndrome: https://www.ncbi.nlm.nih.gov/books/NBK554492/