Hypertensive Encephalopathy and Renal Failure in a Young Man.

A 35-year-old male physician, who worked in a Scottish hospital , became unwell while attending a medical conference in the north of England. His colleagues and family became concerned when they were unable to establish contact with him, prompting a search of the conference facilities. He was found drowsy and confused in his hotel bedroom. This presentation was preceded by 7 weeks of blurred vision and headaches. An arthroscopy had been cancelled 15 years previously because of high blood pressure. The patient was under the impression his blood pressure had normalized over subsequent months but this was not documented. There was no significant family history. He was on no regular medication, was a nonsmoker, and took only occasional alcohol. The patient weighed 180 kg. His blood pressure (BP) in the emergency department was 250/180 mm Hg. He had bilateral posterior shoulder dislocations and had bitten his tongue extensively. He went on to have uncontrolled seizures necessitating intubation and ventilation. After stabilization, fundos-copy revealed bilateral flame hemorrhages and papilledema. He had a stormy course on the Intensive Care unit with recurrent seizures and a failed attempt at extubation. When extubated for the second time, he was immobile because of the shoulder dislocations, cortically blind, and had extensive retrograde amnesia. His BP was initially controlled with intravenous labetalol. Initial investigations revealed significant renal impairment (Table). Urinalysis disclosed blood (+++) and protein (++++). There was no evidence of hemolysis on a blood film. C-reactive protein was elevated, and serum albumin was low, compatible with an inflammatory response. Dhaun: Would you like any further information? What further investigations would you want at this stage if you were looking after this man? Dominiczak: We need to see the kidneys. An ultrasound would be good. Dhaun: Would anybody request a computed tomographic scan of the head? Audience: [Generalized nodding.] Urine. Dhaun: Would you like some more quantification in the urine or analysis of the urine? Audience: Proteinuria Alwakeel: Did you examine the fundus? Fundus examination and listening for arterial bruits (over the renal, carotid and femoral arteries) is important, particularly in a patient with hypertension at such a young age. Dhaun: We did do the fundoscopy and there were flame hemorrhages and papilledema. Staessen: I think in this patient I would do brain imaging and I would do lumbar puncture for cerebrospinal fluid to see if there is any blood in it. Gikonyo: Urine toxicology. I …