Ewha Med J.  2017 Apr;40(2):87-90. 10.12771/emj.2017.40.2.87.

Malignant Hypertension with Pulmonary Alveolar Hemorrhage Needing Dialysis

• Kim Y
• Bang KT
• Shin JH
• Kim JR
• Kim JH
• Jeong JU

• KMID: 2379503
• DOI: http://doi.org/10.12771/emj.2017.40.2.87

Abstract

A 35-year-old man presented with progressive dyspnea and hemoptysis. His blood pressure was 230/140 mmHg and serum creatinine level was 20.13 mg/dL. Chest radiography and computed tomography revealed pulmonary hemorrhage. His renal function was low, thus emergent renal replacement therapy was required. Malignant hypertension and acute kidney injury were diagnosed, and antihypertensive therapy and hemodialysis started immediately. Renal biopsy was performed to examine the underlying disease. Typical pathological changes of malignant hypertension, fibrinoid necrosis of the afferent arterioles, and proliferative endoarteritis at the interlobular arteries were observed. His renal function improved gradually and pulmonary hemorrhage completely disappeared with administration of antihypertensive agents. Here, we report this rare case of malignant hypertension with pulmonary alveolar hemorrhage and speculate that the hemorrhage may be related to vascular injuries at the alveolar capillary level caused by malignant hypertension.

Keyword

Hypertension, malignant; Acute kidney injury; Pulmonary alveoli

MeSH Terms

Acute Kidney Injury
Adult
Antihypertensive Agents
Arteries
Arterioles
Biopsy
Blood Pressure
Capillaries
Creatinine
Dialysis*
Dyspnea
Hemoptysis
Hemorrhage*
Humans
Hypertension, Malignant*
Necrosis
Pulmonary Alveoli
Radiography
Renal Dialysis
Renal Replacement Therapy
Thorax
Vascular System Injuries
Antihypertensive Agents
Creatinine

Figure

• 

  Fig. 1 A chest radiograph and computed tomography image. (A) The radiograph shows bilateral patchy infiltrating shadows with consolidation. (B) The computed tomography image shows multiple and asymmetrical alveolar hemorrhage shadows.

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  Fig. 2 Histologic findings of renal biopsy. (A) A photo micrograph shows a consolidated glomerulus, obliterated arterioles, and marked thinning of the tubular epithelium with dilation of the tubular lumen (periodic acid-Schiff stain, ×200). (B) A photo micrograph shows a consolidated glomerulus without hypercellularity. The capillary lumens are obscured by swollen endothelial cells and expanded subendothelial zones. The arteriole in the middle upper area (or right side) shows obliteration of the lumen by edematous thickening of the intima and multiple layers of periodic acid-Schiff-positive material (onion-skin changes; periodic acid-Schiff stain, ×400). (C) An electron micrograph shows moderate compromise of the capillary lumen due to diffuse subendothelial widening and mesangial expansion, and diffuse effacement of the foot processes of podocytes is noted. (D) An electron micrograph shows red blood cells and fibrin in the arteriolar lumen and platelet aggregation, suggesting fibrin-platelet thrombus consistent with thrombotic microangiopathy.

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  Fig. 3 Blood pressure (BP) and creatinine level. BP normalized gradually, and the serum creatinine (Cr) level decreased abruptly with hemodialysis in the early stage. Final hemodialysis is performed on day 26 of hospitalization, and although the serum Cr level increased slowly, a consistent decrease is noted subsequently. SBP, systolic BP; DBP, diastolic BP.

Reference

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