Unilateral renal artery spasm complicating hypertensive emergency in a patient with secondary aldosteronism

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Renal artery spasm is extremely rare but has been reported in severe hypertension due to pheochromocytoma or ergotamine poisoning. A previously healthy 52-year-old man was referred to our hospital with dyspnoea and disturbance of consciousness. On admission, the level of consciousness was mildly drowsy (E4V5M6), blood pressure was 239/175 mmHg, and pulse rate was 98 bpm. Chest X-ray revealed cardiomegaly and pulmonary congestion (Panel A). Echocardiography demonstrated severe hypertrophy of the left ventricle with preserved ejection fraction (Panel B). Brain magnetic resonance imaging showed marked oedema bilaterally in the cerebrum, brainstem, and cerebellum, consistent with posterior reversible encephalopathy syndrome (PRES) (Panel C, red arrowheads). The diagnosis was congestive heart failure and PRES due to severe hypertension. N-terminal pro-brain natriuretic peptide level, plasma aldosterone concentration, and renin activity were markedly elevated at 46 151 pg/mL, 276 pg/mL, and 18.5 ng/mL/h, respectively. This was accompanied by hypokalaemia (2.95 mmol/L) despite renal dysfunction (creatine 2.17 mg/dL), indicating secondary aldosteronism. Interestingly, ultrasonography revealed stenosis of the right renal artery with a markedly elevated maximum blood flow velocity (3.63 m/s) compared with the left renal artery (0.80 m/s) (Panel D).

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