Case Presentation: A 38-year-old white female with a history of poorly controlled hypertension and reported non-compliance with antihypertensive medications presented with fatigue, headache, blurry vision, and gross hematuria. On admission, she was found to be in hypertensive emergency with a blood pressure of 258/168 mmHg and was transferred to the neuro intensive care unit for altered mental status. Brain MRI was concerning for atypical posterior reversible encephalopathy syndrome (PRES), but CNS malignancy, osmotic demyelination, and autoimmune encephalitis were also considered. Extensive autoimmune, infectious, and vessel wall imaging workups were unremarkable. Laboratory workup revealed acute kidney injury (AKI) and thrombocytopenia, prompting concern for thrombotic thrombocytopenic purpura (TTP) or hemolytic uremic syndrome (HUS). Nephrology and hematology teams were consulted for further evaluation. Differential Diagnosis: PRES, CNS lymphoma, autoimmune encephalitis, osmotic demyelination syndrome, TTP/HUS, and hypertensive nephrosclerosis were all considered. The unremarkable CNS and hematologic workups, coupled with renal biopsy findings of thrombotic microangiopathy (TMA), helped narrow the diagnosis. Treatment and Management: Management included aggressive blood pressure control and supportive care. The patient required two sessions of hemodialysis for uremia and fluid overload. No plasmapheresis or immunosuppressive therapy was initiated, as TMA was attributed to malignant hypertension rather than a primary TMA syndrome. Outcome and Follow-Up: The patient's renal function gradually improved without further need for dialysis. Neurologic status returned to baseline, and imaging findings evolved in a pattern consistent with resolving PRES. The patient was discharged in stable condition with close outpatient follow-up. Teaching Points: This case underscores malignant hypertension as a potential cause of TMA with multi-organ involvement. Non-adherence with antihypertensive medications can lead to life-threatening complications such as renal failure. A multidisciplinary approach focusing on prompt blood pressure control, both in the outpatient and inpatient settings, may lead to clinical improvement and overall quality of life.
Joyce et al. (Mon,) studied this question.