225. Linezolid-induced Posterior Reversible Encephalopathy Syndrome: A Case Report and Review of the Literature

Article type: Case Reports
Article title: Linezolid-induced Posterior Reversible Encephalopathy Syndrome: A Case Report and Review of the Literature

Journal: Clinical Neuropharmacology
Year: 2026
Authors: Jamir Pitton Rissardo, Priya Shah, Kaitlyn Piotrowski, Aswathi Sajeendran, Ana Leticia Fornari Caprara, Olga R. Thon, Joshua Santucci

ABSTRACT
Background/Aim: Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic condition characterized by vasogenic edema, altered mental status (AMS), seizures, headaches, and visual disturbances. It is commonly associated with hypertension, cytotoxic drugs, and autoimmune disorders. We report a rare case of PRES likely related to linezolid therapy. Case Report: A 77-year-old female with renal cell carcinoma, rheumatoid arthritis, hypertension, and prior thromboembolic events underwent major abdominal surgery complicated by coagulopathy, hemorrhage, and sepsis. Blood cultures grew Enterococcus faecium, and linezolid was initiated. Within 48 hours, she developed AMS and respiratory distress requiring intubation. EEG showed epileptiform discharges, and MRI revealed subarachnoid and intraparenchymal hemorrhage with features of PRES. Linezolid was discontinued, and follow-up MRI demonstrated improvement in bilateral hemispheric edema and hemorrhage. A literature review identified 2 additional cases of linezolid-associated PRES, both with similar neurological symptoms but without hemorrhagic complications. Unlike prior reports, our patient had a prolonged recovery, with only partial improvement at 19 days, likely influenced by comorbidities and associated hemorrhagic lesion. Conclusions: Linezolid-induced PRES is rare but clinically significant. Our case highlights potential hemorrhagic complications and delayed recovery, underscoring the need for early recognition and prompt management.
Keywords: linezolid, antibiotics, adverse drug reactions, drug-induced neurotoxicity, PRES, posterior reversible encephalopathy syndrome, magnetic resonance imaging.


DOI

Citation
Rissardo JP, Shah P, Piotrowski K, Sajeendran A, Fornari Caprara AL, Thon OR, Santucci J. Linezolid-induced Posterior Reversible Encephalopathy Syndrome: A Case Report and Review of the Literature. Clin Neuropharmacol 2026;49:107-113.
Figure 1. Point-of-care EEG evaluation using Ceribell, demonstrating no seizure burden (A) and EEG findings (B) characterized by a background of diffuse delta activity at 3 to 4 Hz alternating with diffuse theta activity during stimulation. The EEG also revealed intermittent periodic sharp delta waves over the frontocentral regions, occasionally displaying triphasic morphology, along with intermittent sharp and slow wave discharges localized to the right frontotemporal area.
Figure 2. Neuroimaging showing improvement of bilateral temporal and frontal abnormalities. First brain MRI sequences axial FLAIR (A and B) and T2-weighted fast spin echo (C). Eighteen 18 days later, second brain MRI sequences axial FLAIR (D and E) and T2- weighted fast spin echo (F).
Figure 3. Schematic diagram of the pathophysiology of linezolid-induced PRES. A, Normal conditions showing expected penetration of linezolid across the BBB. B, Increased CNS penetration of linezolid in the setting of BBB disruption, commonly associated with risk factors such as hypertension and chronic kidney disease. This disruption is linked to pericyte injury, mitochondrial dysfunction, and inflammatory changes, resulting in vasogenic edema and the development of PRES.
Table 1. Cases of Linezolid-induced Posterior Reversible Encephalopathy Syndrome.