Malignant hypertension with a rare complication of pulmonary alveolar hemorrhage

Diffuse Alveolar Hemorrhage: A Rare Complication of Severe Hypertension

Severe hypertension is a rare cause of diffuse alveolar hemorrhage. We reported a case of a 43-year-old woman who presented with shortness of breath, hemoptysis, and severe hypertension. The patient was diagnosed with diffuse alveolar hemorrhage due to severe hypertension which improved after controlling her blood pressure.

Association between High Blood Pressure in the Emergency Department and Cryptogenic Hemoptysis

Hemoptysis is a common cause of emergency department (ED) visits. There is little data about the role of systemic hypertension as a cause of hemoptysis. The aim of this study was to evaluate the association between systemic blood pressure and the unknown etiology of hemoptysis. This retrospective study included consecutive patients who visited the ED owing to hemoptysis and underwent a chest computed tomography between January 2011 and June 2021. Details of the initial blood pressure at the ED visit were compared between two groups with identified and unidentified causes of hemoptysis. In total, 1105 adult patients were included. The etiology of hemoptysis was identified in 1042 patients (94.3%) and remained unidentified in 63 patients (5.7%). The percentage of patients with severe hypertension was significantly higher in patients with unidentified causes of hemoptysis than in those with identified causes (35% vs. 11%, p < 0.001). In multivariate analysis, age, ever-smoker, and initial systolic blood pressure were significantly associated with hemoptysis of unidentified causes. Although further studies are needed, our findings suggest a possible association between high blood pressure and cryptogenic hemoptysis.

A rare case of alveolar hemorrhage with hypertensive emergency

INTRODUCTION

Alveolar hemorrhage presents with severe respiratory failure, requiring prompt diagnosis and treatment. Alveolar hemorrhage is often caused by autoimmune diseases accompanied by progressive renal dysfunction. However, few cases without autoimmune diseases occur, making diagnosis difficult. Here, we report a case of alveolar hemorrhage with hypertensive emergency.

PATIENT CONCERNS

A 28-year-old man presented with dyspnea and bloody sputum. His blood pressure was 200/120 mm Hg.

DIAGNOSIS

The chest computed tomography showed suggestive of alveolar hemorrhage. Renal dysfunction and proteinuria were observed. However, autoantibodies were not detected. Echocardiogram revealed left ventricular function decrease. Ejection fraction was 20% to 30% with no ventricular asynergy or any valvular diseases. Brain magnetic resonance imaging showed hyperintense lesions on fluid-attenuated inversion recovery in the white matter of both cerebral and right cerebellar hemispheres, which were compatible with posterior reversible encephalopathy syndrome. Renal biopsy did not reveal any immune-mediated glomerulonephritis or vasculitis, but hypertensive nephropathy was diagnosed.

INTERVENTIONS

Blood pressure was controlled with combination therapy using calcium channel blocker, angiotensin II receptor blocker, α1 blocker, and β blocker.

OUTCOMES

Alveolar hemorrhage and proteinuria improved with strict blood pressure control.

CONCLUSION

This case indicates that severe hypertension can possibly cause alveolar hemorrhage. Accumulating these cases is important for general physicians to diagnose the alveolar hemorrhage with hypertensive emergency in its early stage and to avoid unnecessary treatment such as immunosuppressive therapy.

Diffuse Alveolar Hemorrhaging with Hypertensive Emergency: A Rare but Important Cause of Hemoptysis

Hypertensive emergency, which occurs even in young adults, induces systemic organ damage and results in a poor prognosis. We herein report the case of a 27-year-old man who developed alveolar hemorrhaging with hypertensive emergency. He presented with bloody sputum, renal failure, and extremely high blood pressure (200/128 mmHg). Chest computed tomography revealed diffuse bilateral alveolar infiltrates suggestive of diffuse alveolar hemorrhaging. After intensive therapy with anti-hypertensive drugs, the alveolar hemorrhaging disappeared. Renal impairment was partially reversed. Therefore, we conclude that hypertensive emergency should be considered as a possible cause of hemoptysis, even in young adults.

Malignant Hypertension Causing a Pulmonary-Renal Syndrome

Background

Pulmonary-renal syndrome is characterised by acute kidney injury, haematuria, and haemoptysis and is a well-recognised presentation of diseases such as ANCA vasculitis that require urgent immunosuppression.

Case Presentation

A patient presented with a brief history of haemoptysis, acute renal failure, microscopic haematuria, and severe hypertension. The diagnosis was initially not clear so he was treated with antihypertensives, renal replacement therapy, and immunosuppression. Renal biopsy subsequently showed evidence of malignant hypertension. Autoantibodies were uniformly negative.

Conclusions

This case demonstrates that malignant hypertension can present as pulmonary-renal syndrome.

Diffuse Alveolar Hemorrhage Due to Malignant Arterial Hypertension – an Unusual Manifestation of a Common Disease

Diffuse alveolar hemorrhage is a clinicopathological syndrome that often leads to respiratory failure, with associated hemoptysis and anemia. Chest radiograph presents non-specific findings of perihilar infiltrates, while computed tomography shows ground-glass attenuation or areas of consolidation with interlobular septal thickening. Bronchoalveolar lavage is used to confirm the clinical and radiological suspicion.

While vasculitis and other causes of pulmonary renal syndrome are the most common causes of diffuse alveolar hemorrhage, malignant hypertension should be considered in the proper clinical setting. We present a case report of a 51-year-old previously healthy patient that was diagnosed with diffuse alveolar hemorrhage and acute renal failure due to malignant hypertension, through clinical and radiological findings.

Central blood pressure and chronic kidney disease

In this review, we focused on the relationship between central blood pressure and chronic kidney diseases (CKD). Wave reflection is a major mechanism that determines central blood pressure in patients with CKD. Recent medical technology advances have enabled non-invasive central blood pressure measurements. Clinical trials have demonstrated that compared with brachial blood pressure, central blood pressure is a stronger risk factor for cardiovascular (CV) and renal diseases. CKD is characterized by a diminished renal autoregulatory ability, an augmented direct transmission of systemic blood pressure to glomeruli, and an increase in proteinuria. Any elevation in central blood pressure accelerates CKD progression. In the kidney, interstitial inflammation induces oxidative stress to handle proteinuria. Oxidative stress facilitates atherogenesis, increases arterial stiffness and central blood pressure, and worsens the CV prognosis in patients with CKD. A vicious cycle exists between CKD and central blood pressure. To stop this cycle, vasodilator antihypertensive drugs and statins can reduce central blood pressure and oxidative stress. Even in early-stage CKD, mineral and bone disorders (MBD) may develop. MBD promotes oxidative stress, arteriosclerosis, and elevated central blood pressure in patients with CKD. Early intervention or prevention seems necessary to maintain vascular health in patients with CKD.

Malignant hypertension with an unusual presentation mimicking the immune mediated pulmonary renal syndrome

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.

A patient with hemoptysis and renal failure

Pulmonary-renal syndrome is a medical emergency; etiology of which has broad differential diagnosis. Delay in both diagnosis and initiation of management may result in end-organ damage. Management decisions may have to be empiric till a rapid, definitive tissue diagnosis is established. We present such a case where prompt recognition and immediate treatment was initiated, although the patient sustained irreversible end-organ damage. The case also highlights the need to interpret the kidney biopsy data (namely, immunofluroscence findings) in the context of clinical presentation.

Hepatitis B-related polyarteritis nodosa complicated by pulmonary hemorrhage

A 34-year-old man presented with fever, weight loss, paresthesia, abdominal pain, and hypertension. He had hepatitis B antigenemia, with negative antineutrophil cytoplasmic antibody, antinuclear antibody, and antiglomerular basement membrane serology results. Renal arteriography showed multiple intrarenal microaneurysms. In spite of therapy with antiviral agents (lamivudine, famciclovir), prednisone, cyclophosphamide, and plasmapheresis, renal function deteriorated. He later developed rapidly progressive dyspnea and hemoptysis. Diffuse alveolar hemorrhage was confirmed by bronchoscopy. He died of respiratory failure. The cause of pulmonary hemorrhage in this case of polyarteritis nodosa is unclear, but may include underlying capillaritis, cocaine-induced pulmonary hemorrhage, or recurrent attacks of malignant hypertension.