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Case: An 80-year-old woman was admitted to our hospital with lower extremity weakness. She was treated for hypertension (HT), type 2 diabetes, and Alzheimer's disease.Her medications included brotizolam 0.25 mg, rivastigmine tape 18 mg, celecoxib 200 mg, sofarcon 50 mg, losartan 50 mg, hydrochlorothiazide 12.5 mg, rosuvastatin 2.5 mg, propiverine 10 mg, empagliflozin 10 mg, linagliptin 5 mg, esomeprazole 20 mg, peony and licorice formula (PLF) 7.5 grams, and olopatadine 5 mg.On admission her blood pressure (BP) was 191/73 mmHg.Manual muscles testing (MMT) for the upper limbs was 4/5 bilaterally throughout. Lower limb MMT included iliopsoas 1/5, quadriceps 1/5, hamstrings 1/5, anterior tibialis 4/5, gastrocnemius 4/5 bilaterally, respectively.Basic blood tests revealed serum K + 2.0 mEq/L, urinary K + 21.0 mEq/L, creatinine kinase 1,488 U/L, renin activity 0.8 ng/mL/hr, and aldosterone 4.0 pg/mL (CLEIA method).During admission to the intensive care unit, frequent blood sampling was performed to correct the serum K+ level. A calcium channel blocker (CCB) was commenced for HT on admission day. Spironolactone was commenced on postadmission day (PAD) 1. The serum K+ level stabilized, and potassium chloride administration was terminated PAD 6. BP also improved over time, and the CCB was discontinued on PAD 23. On the same day, she was discharged from the hospital with continuation of spironolactone.In this case, there were a total of 11 prescription drugs including PLF from three clinics. We diagnosed HT and lower extremity weakness due to pseudohyperaldosteronism (PHA). The HT improved after discontinuation of PLF.Licorice is found in about 70% of Chinese herbal medicines. Risk factors for PHA include short stature and weight, elderly and female, renal dysfunction, and diuretic administration. As Japan has entered a super-aging society, the number of patients using geriatric healthcare facilities and chronic care wards is increasing. The frequency of blood sampling is particularly low in such facilities, so it is difficult to notice hypokalemia among such patients. PHA and hypokalemic myopathy due to licorice should be considered in the case of lower limb weakness in elderly patients.

A 17-year-old female was referred to our department with hypertension refractory to medical treatment. When she presented to the otolaryngologist 3 years earlier for dizziness, her systolic blood pressure was 170 mmHg. On physical examination, her blood pressures in right and left arms were 193/99 and 196/106 mm Hg, respectively. Also, a systolic ejection murmur of grade 2/6 was present at the left upper sternal border. She was prescribed cilnidipine 20 mg/day and nifedipine CR 40 mg/day, but her blood pressure was 160/90 mmHg. Plasma renin activity was 5.2 ng/ml/h, and serum aldosterone was 210.4 pg/ml, so renovascular hypertension was suspected. However, contrast-enhanced 3-dimensional computed tomography (3DCT) of the both renal arteries showed no stenosis. On the other hand, renal doppler ultrasound revealed a slow rise in systolic blood flow waveform in both renal arteries and intrarenal arteries. This indicates that the vessel upstream of the measurement site is stenotic. The similar blood flow waveform was observed in the abdominal aorta, suggesting aortic stenosis upstream of the abdominal aorta. 3DCT of the thoracic aorta revealed a significant coarctation of the thoracic aorta distal to the origin of the left subclavian artery. We diagnosed her as coarctation of the aorta, and performed a descending aortic replacement procedure. As a result, her blood pressure decreased to 130/80 mmHg under cilnidipine 20 mg/day. The waveform of both renal arteries, intrarenal arteries and abdominal aorta became a normal pattern by doppler ultrasound. Hypertension in adolescent is uncommon. As secondary causes are more commonly found in this age group than in older adults, aortic coarctation should be considered. Early diagnosis and treatment are essential for the prevention of morbidity and mortality from premature cardiovascular complications. Here, we described a case of coarctation of the aorta that doppler ultrasound was useful for investigating the cause of adolescent refractory hypertension.

The diverse histological findings in IgA nephropathy are often evaluated using the Oxford classification for glomerular, tubular/interstitial, and vascular lesions. Patients with IgA nephropathy are prone to hypertension, but the relationship between the histological findings and blood pressure (BP) is not well known. In addition to systolic BP (SBP) and diastolic BP (DBP), mean arterial pressure (MAP) as a steady component and pulse pressure (PP) as a pulsatile component are also important BP components. Therefore, we investigated the detailed relationship between these BP components and renal histological findings. Conclusion:The study was clearly revealed that the treatment protocol of ISH guidelines in adults was not accordingly so proper CMEs must be conducted to aware the health care professionals.