A LONG FORGOTTEN DIAGNOSIS – A CASE OF MALIGNANT HYPERTENSION

Abstract

Objective: Malignant hypertension is a severe form of hypertension (HTN) classified as a hypertensive emergency, whose occurrence is rather rare given compared to the time it entered the medical lexicon, given the nowadays ample blood pressure (BP) lowering therapeutic arsenal. We present the case of a patient with acutely decompensated heart failure due to malignant HTN. Design and method: A 66 years old diabetic, chronic renal disease, obese, female patient presented to the emergency department for a five days onset of hallucinations and confusion. She described dyspnea on mild-moderate efforts, headache and vertigo for the past six months, lacking BP control for the past two years on a four-drug regimen including perindopril, amlodipine, bisoprolol, and furosemide. Clinical evaluation found no signs of stroke, but significant systemic and pulmonary congestion, BP levels 250/160 mmHg (equal both arms), and bilateral flame haemorrhages and papilloedema on fundoscopy. CT scan was positive for cerebral edema and echocardiography showed left ventricle hypertrophy with an ejection fraction of 40%, diffuse hypokinesis, with no significant valvulopathy. Upon admission the patient received urapidil during the first 24 h, on top of high dose loop diuretic and a six-drug regimen including an ACE inhibitor, calcium channel blocker, spironolactone, betablocker and two central acting antihypertensives. 24 h and 72 h control CT scan did not reveal any changes; nephrotic range proteinuria (17 g/24 h) was also noted along with a moderate increase in creatinine levels once BP control was obtained. Results: Congestion and neurological symptoms were significantly improved during the two-week course of above mentioned therapy and patient was discharged. Control at one month revealed an asymptomatic patient with good BP control at 110/90 mmHg and improved cardiac function, persistent but lower proteinuria, however with significantly increased serum creatinine levels. This led to a step-down in antihypertensive therapy aiming for a systolic BP of 130–139 mmHg. Conclusions: This is a case of refractory hypertension aggravated by inertia to seek medical advice and secondary poor BP control. This led to a severe form of malignant hypertension in which adequate control was obtained with difficulty and over a long period of time.