CASE REPORT: HELLP-LIKE SYNDROME IN A 19-YEAR-OLD WOMAN WITH NOT WELL - CONTROLLED HYPERTENSION

Abstract

Objective: We report a young woman with malignant hypertension (HTN) and multiorgan damage due to microangiopathy. Design and method: A 19-year old woman with previously recognized HTN and family history of HTN developed acute symptoms related to long-standing not well-controlled HTN. The patient presented with high blood pressure (BP), vomiting, epigastric pain, jaundice, impaired consciousness, tonic-clonic seizures, complete left eye blindness and partial right eye blindness. On admission, the patient was conscious but obtunded, with marked cognitive dysfunction, BP 255/143 mm Hg, heart rate 130 bpm, breathing rate 34/min, temperature 36,9C, SpO2 95%. Following admission, a transient loss of consciousness with eyes turning to the left was observed upon sitting up, without any arrhythmia seen in ECG monitoring. Neurological examination was unremarkable. Fundoscopy showed grade IV changes with papilledema, numerous hemorrhages and cotton wool spots. Results: Pregnancy test was negative. Laboratory test abnormalities included macrocytic anemia (Hb 10.25 g/dL, Hct 33.6%, MCV 103 fL), elevated leukocyte count (17.1x10 3 /L), low platelet count (69x10 3 /L), elevated serum bilirubin (10.4 mg/dL) and creatinine (4.2 mg/dL), and slightly elevated AspAT and troponin I. Brain CT showed chronic vascular brain damage. BP was gradually normalized using intravenous/oral antihypertensive drugs. Clinical symptoms and laboratory abnormalities resolved, except for left eye blindness and serum creatinine (2.47 mg/dL at discharge). Secondary HTN was excluded. The final diagnosis was malignant HTN, acute hypertensive encephalopathy with seizures, acute liver damage, chronic kidney disease, acute hemolytic anemia due to hypertensive microangiopathy, and permanent left eye blindness. Due to hemolysis and low platelet count, differential diagnosis included hemolytic-uremic syndrome which was excluded. The clinical presentation resembled that of HELLP syndrome in pregnant women with eclampsia, with evidence of target organ damage, low platelet count, liver and kidney dysfunction, and hemolytic jaundice. Conclusions: Young patients with essential HTN rarely present with such fulminant malignant HTN manifesting with neurological symptoms, with evidence of multiorgan damage due to microangiopathy. Similarly, microangiopathic hemolytic anemia rarely complicates malignant HTN. Initial clinical presentation was challenging due to neurological symptoms and evidence of multiorgan failure.