JS-AHA: AHA SESSION CLINICAL CASE; CLINICAL-PATHOLOGICAL CONFERENCE (CPC) IN COOPERATION WITH HYPERTENSION, AN AMERICAN HEART ASSOCIATION JOURNAL

Abstract

A 35-year-old woman, with a known history of right renal artery FMD, presented at the Hypertension Outpatient Clinic for evaluation of resistant hypertension. The patient was an active smoker and had a single kidney after left nephrectomy for kidney malformation during childhood. The diagnosis of FMD had been made on the occasion of a previous pregnancy at 23 years, complicated by preeclampsia and an angioplasty had been performed. Work-up disclosed a recurrence of right renal artery stenosis, and a new renal angioplasty was performed. Blood pressure normalized after the procedure. At 36 years, the patient had another pregnancy, also complicated by preeclampsia and preterm delivery. An Echo-Doppler performed during pregnancy and an Angio-CT after delivery, allowed ruling out recurrence of renal artery stenosis. At 43 years, she was admitted to the emergency room for thoracic pain. The coronarography was in favour of a coronary spasm. There was no coronary stenosis or image suggestive of a Spontaneous Coronary Artery Dissection. At 54 years, the patient was again admitted in emergency for malignant hypertension associated with severe acute renal failure. She also reported a history of lower limbs claudication since several months. An abdominal CT disclosed dissection complicated by occlusion of the right renal artery, dissection of both iliac arteries as well as a severe stenosis of the infra-renal aorta. An angioplasty with insertion of stents in the right renal artery and the aorta was performed. After the procedure, a partial normalization of renal function was observed, and blood pressure control was achieved on 3 medications. During the recovery, the patient presented a skin rash associated with a general feeling of discomfort, with spontaneous resolution after a few days. One year later, following a control Angio-CT of the abdomen, an anaphylaxis episode occurred, requiring Adrenaline administration. Iodine contrast allergy was suspected, but milder hypersensitivity symptoms occurred in the following months, without exposition to a clear trigger. An allergology work-up was performed with final diagnosis of secondary Mast Cell Activation Syndrome. B-Blockers and ACE-inhibitors were contra-indicated and cautious premedication before further exposure to iodine contrast was recommended.