Cerebral microbleeds with posterior reversible encephalopathy syndrome: A rare complication in acute lymphoblastic leukaemia

Cerebral microbleeds are a rare entity usually seen in hypertensive microangiopathy or amyloid angiopathy. Its occurrence in Acute Lymphoblastic Leukaemia (ALL) has not been reported so far. Clinicians while treating patients should be aware of such complications for timely diagnosis and management. This is a case report on 19-year-old male, who was on treatment for ALL, under induction phase of the Berlin-Frankfurt-Munster-95 (BFM-95) regimen, who developed one episode of generalised tonic-clonic seizures. The MRI brain in T2 sequence showed hyperintense lesions in the white matter of occipital region, suggestive of Posterior Reversible Encephalopathy Syndrome (PRES). Susceptibility Weighted Imaging (SWI) showed multifocal areas of blooming in bilateral cerebral hemispheres suggestive of microbleeds. The fibrinogen level was very low strongly suggestive of L-Asparaginase induced microbleeds. The patient was treated with antiepileptic and cryoprecipitate transfusion to maintain fibrinogen levels and further doses of L-Asparaginase were withheld. He recovered without any neurological sequelae.