Unusual Case of Severe Hypertension in a 20-Year-Old Woman

Abstract

A 20-year-old woman was seen in the emergency department because of abdominal pain and hypertension. The patient had no notable medical history, and there were no inherited disorders in her family. She had been well until 1 month before admission, when a sharp, constant, and diffuse abdominal pain developed. The pain was not modified by food intake, defecation or positional changes. The patient did not report anorexia, nausea, retching, or changes in her bowel habits. She had not experienced menstrual disorders or irritative urinary symptoms. Two days before admission a mild generalized headache developed. The patient had been seen in the emergency department 9× since the onset of symptoms, being discharged with different diagnosis including cystitis and nephritic colic among others. Abdominal ultrasonography was normal, and the gynecological evaluation did not show abnormalities. Over the past month, she had been prescribed analgesics and nonsteroidal anti-inflammatory drugs, prokinetics, spasmolytics, and antibiotics, without clinical improvement.At admission, on physical examination, the patient was alert, uncomfortable but cooperative. Temperature was 36.3°C, blood pressure (BP) was 166/111 mm Hg, pulse was 120 bpm, respiratory rate was 18 breaths/min, and oxygen saturation was 98%. The abdomen was soft and nondistended, with soft bowel sounds and absence of bruits, without hepatomegaly or splenomegaly, or signs of peritoneal inflammation. Peripheral pulses were regular and symmetrical without carotid-femoral delay. The neurological examination did not reveal any abnormality. The laboratory test showed mild hyponatremia (serum sodium, 126 mmol/L) with normal potassium levels (3.8 mmol/L), mild elevation of transaminases and mild leukocytosis (white-cell count, 15 100/mm 3 with 80.1% segmented neutrophils), the rest of the analytic profile was normal (Table S1 in the online-only Data Supplement). Electrocardiography tracing on sinus rhythm was without signs of left ventricular hypertrophy or myocardial ischemia. Cerebral computed tomographic scan revealed bilateral hypodense lesions in the subcortical white matter of the occipital area. The fundoscopic examination showed a normal fundus without vessel alterations. Urinalysis, abdominal ultrasonography, abdominal computerized tomographic scan, and chest radiograph did not show abnormalities. A review of clinical chart and laboratory values obtained in the emergency department in the last month revealed BP values above 140/90 mm Hg and persistent hyponatremia. The patient was admitted to the hospital and treated with 10 mg of amlodipine once daily.At admission, the patient developed 2 self-limited episodes of blurry vision, which lasted ≈45 minutes each and were accompanied by mild generalized headache without vegetative symptoms. She also reported progressive muscle weakness. The general and neurological examination was repeatedly normal except for the absence of the patellar reflex, and her BP was 145/105 mm Hg. Magnetic resonance imaging of the brain confirm...

Acute porphyrias – A neurological perspective

“…In the literature, 53 cases with PRES-like lesions in brain MRI during acute porphyric attacks are reported (Aggarwal et al, 1994;Bhat et al, 2010;Bhuyan et al, 2014;Bicknell & Stewart, 2011;Black et al, 1995;Bonkovsky et al, 2008;Celik et al, 2002;Dagens & Gilhooley, 2016;Dahlgren et al, 2011;Divecha et al, 2016;Engelhardt et al, 2004;Garg et al, 1999;Gurses et al, 2008;Jaramillo-Calle et al, 2019;Kang et al, 2010;King & Bragdon, 1991;Kuo et al, 2011;Kupferschmidt, 1995;Lakhotia et al, 2015;Lambie et al, 2018;Maramattom et al, 2005;Mullin et al, 2012;Mutyaba et al, 2011;New et al, 2016;Olivier et al, 2017;Park et al, 2014;Pichler et al, 2015;Sakashita et al, 2017;Sanz et al, 2016;Shen et al, 2008;Silveira et al, 2016;Soysal et al, 2008;Susa et al, 1999;Takata et al, 2017;Utz et al, 2001;Webb et al, 2016;Wessels et al, 2005;Yang et al, 2017;Yen et al, 2002;Yrjonen et al, 2008;…”

“…In the literature, 53 cases with PRES‐like lesions in brain MRI during acute porphyric attacks are reported (Aggarwal et al., 1994; Bhat et al., 2010; Bhuyan et al., 2014; Bicknell & Stewart, 2011; Black et al., 1995; Bonkovsky et al., 2008; Celik et al., 2002; Dagens & Gilhooley, 2016; Dahlgren et al., 2011; Divecha et al., 2016; Engelhardt et al., 2004; Garg et al., 1999; Gurses et al., 2008; Jaramillo‐Calle et al., 2019; Kang et al., 2010; King & Bragdon, 1991; Kuo et al., 2011; Kupferschmidt, 1995; Lakhotia et al., 2015; Lambie et al., 2018; Maramattom et al., 2005; Mullin et al., 2012; Mutyaba et al., 2011; New et al., 2016; Olivier et al., 2017; Park et al., 2014; Pichler et al., 2015; Sakashita et al., 2017; Sanz et al., 2016; Shen et al., 2008; Silveira et al., 2016; Soysal et al., 2008; Susa et al., 1999; Takata et al., 2017; Utz et al., 2001; Webb et al., 2016; Wessels et al., 2005; Yang et al., 2017; Yen et al., 2002; Yrjonen et al., 2008; Zhang et al., 2017; Zhao et al., 2014; Zheng et al., 2018). Described lesions are symmetrical or asymmetrical, ranging from bioccipital white matter lesions to gyriform cortical lesions, some show contrast enhancement (Aggarwal et al., 1994; Black et al., 1995; Maramattom et al., 2005; Susa et al., 1999; Zhao et al., 2014; Zheng et al., 2018) and most are in posterior circulation territories.…”