Yonsei Med J.  2012 Nov;53(6):1224-1227. 10.3349/ymj.2012.53.6.1224.

Malignant Hypertension with an Unusual Presentation Mimicking the Immune Mediated Pulmonary Renal Syndrome

• Park HS
• Hong YA
• Chung BH
• Kim HW
• Park CW
• Yang CW
• Jin DC
• Kim YS
• Choi BS

• KMID: 1414269
• DOI: http://doi.org/10.3349/ymj.2012.53.6.1224

Abstract

A 27-year-old man presented at the emergency room with hemoptysis. His blood pressure was 180/100 mm Hg, and he had no history of hypertension. Chest radiographs showed bilateral infiltration, suggestive of alveolar hemorrhage. His laboratory data were consistent with acute kidney injury. His serum creatinine level increased abruptly; therefore, renal biopsy was performed. Steroid pulse therapy was administered because of a strong suspicion of immune-mediated pulmonary renal syndrome. Renal biopsy showed proliferative endarteritis, fibrinoid necrosis, and intraluminal thrombi in the vessels without crescent formation or necrotizing lesions. Steroid pulse therapy rapidly tapered and stopped. His serum creatinine level gradually decreased with strict blood pressure control. Ten months after discharge, his blood pressure was approximately 120/80 mm Hg with a serum creatinine level of 1.98 mg/dL. Pulmonary renal syndrome is generally caused by an immune-mediated mechanism. However, malignant hypertension accompanying renal insufficiency and heart dysfunction causing end-organ damage can create a pulmonary hemorrhage, similar to pulmonary renal syndrome caused by an immune-mediated mechanism. The present case shows that hypertension, a common disease, can possibly cause pulmonary renal syndrome, a rare condition.

Keyword

Malignant hypertension; hemoptysis; pulmonary renal syndrome

MeSH Terms

Adult
Glomerulonephritis/*diagnosis
Hemoptysis/pathology
Hemorrhage/*diagnosis
Humans
Hypertension, Malignant/*diagnosis
Lung Diseases/*diagnosis
Male

Figure

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  Fig. 1 Chest radiograph showing infiltration in both lower lobes and cardiomegaly.

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  Fig. 2 Fundoscopic examination showing multiple cotton wool spots and a splinter hemorrhage.

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  Fig. 3 Light microscopy examination showing intima fibrous hyperplasia, smooth muscle cell hyperplasia in the media of interlobular artery, and a collapsed glomerulus by ischemia (H&E ×200).

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