Fatigue with malignant hy...

A 33-year-old woman was referred to the Internal Medicine Department by her GP after the recent diagnosis of severe hypertension. The diagnosis of hypertension dated back to the day before; however, its onset was actually unknown, as the patient had no memory of having ever measured her blood pressure before, consistent with the low awareness that young adults have of their hypertension. During the visit, she complained of fatigue. Otherwise, her medical and family histories were unremarkable. She used to smoke no more than 5 cigarettes per day, did not take any prescription or over-the-counter medications and denied the use of recreational drugs, as confirmed by the negativity of the urine drug screening. 

 

Examination

 

On admission, her blood pressure was 240/140 mmHg; her other vital signs were normal, and her physical examination was unremarkable. Initial laboratory studies identified the presence of renal failure (creatinine 2.11 mg/dL), hypokalaemia (potassium 2.45 mEq/L), and anaemia with thrombocytopenia (haemoglobin 10.6 g/dL, platelets 113.000/microm3), which were likely to be haemolytic as LDH was elevated (572 U/L). There was also an elevated CRP level of 170 mg/L. As for end-organ damage, renal failure was associated with a proteinuria of 1.9 g over 24 h, while ultrasound revealed two normal-sized kidneys with echogenic parenchyma. The ECG showed signs of left ventricular hypertrophy, which was confirmed by echocardiography, as the interventricular septum thickness measured 19 mm and LV mass/BSA was 232 g/m2. The left ventricular ejection fraction was 50 %, and there was no aortic coarctation. Retinal examination revealed grade III hypertensive retinopathy, showing the presence of malignant hypertension, and antihypertensive drugs were promptly administered. 

 

A week after the start of the antihypertensive therapy, not only CRP, but also haemoglobin, platelets, and LDH normalized, so that we ruled out also other conditions causing renal failure. A CT scan of the abdomen, renal duplex ultrasound and kidney biopsy were done.