1/2777. Aortic dissection in young patients with chronic hypertension. We describe four patients aged 14 to 21 years who developed acute aortic dissection. In three of the four patients, the course was fatal, despite aggressive medical and surgical intervention. All four patients had sustained systemic hypertension related to chronic renal insufficiency. The patients had no other identifiable risk factors for aortic dissection, including congenital cardiovascular disease, advanced atherosclerosis, vasculitis, trauma, pregnancy, or family history of aortic dissection. Although aortic dissection is rare in individuals younger than 40 years of age, young patients with sustained systemic hypertension are at increased risk for this serious and often fatal condition. physicians must be aware of this rare complication of hypertension and consider aortic dissection in the differential diagnosis of unusual chest, abdominal, and back pain in hypertensive children, adolescents, and young adults. ( info) |
2/2777. Late onset angiotensin-converting enzyme induced angioedema: case report and review of the literature. angiotensin-converting enzyme inhibitors (ACEI) such as enalapril, captopril, and lisinopril are well established as effective treatments of arterial hypertension and congestive heart failure. They are widely used and generally well tolerated. angioedema is a rare but serious adverse effect of ACEI therapy. Most frequently, edema involves the face, oral cavity, and the glossopharyngeal or glottic area. Visceral edema induced by ACEI has also occurred. life threatening and even fatal cases associated with ACEI have been reported. Although angioedema typically occurs within the first weeks of ACEI therapy, some cases with latencies of several months to years have been reported. This paper reports a case of late onset and recurrent angioedema in a patient treated with lisinopril for hypertension. A discussion of ACEI angioedema follows. ( info) |
3/2777. Adrenal cancer with hypertension but low plasma renin and aldosterone. patients with malignant lesions of the adrenal gland may present with a syndrome of excess mineralocorticoids. Both primary hyperaldosteronism and excess mineralocorticoids other than aldosterone resulting from adrenal carcinoma have rarely been reported. In most patients with adrenal tumors secreting mineralocorticoids other than aldosterone, distant metastasis had already occurred at the time of diagnosis and the prognosis was poor. We present a rare case of adrenal cancer with hypertension in a patient with low plasma renin activity and a low plasma aldosterone concentration. The patient's blood pressure returned to normal after removal of the tumor. The patient is still alive and without recurrence 6 years after surgery. This case illustrates the value of thorough evaluation of hypertension and prompt surgical treatment for patients with adrenal cancer. ( info) |
4/2777. The elevated serum alkaline phosphatase--the chase that led to two endocrinopathies and one possible unifying diagnosis. A 39-year-old Chinese man with hypertension being evaluated for elevated serum alkaline phosphatase (SAP) levels was found to have an incidental right adrenal mass. The radiological features were characteristic of a large adrenal myelolipoma. This mass was resected and the diagnosis confirmed pathologically. His blood pressure normalised after removal of the myelolipoma, suggesting that the frequently observed association between myelolipomas and hypertension may not be entirely coincidental. Persistent elevation of the SAP levels and the discovery of hypercalcaemia after surgery led to further investigations which confirmed primary hyperparathyroidism due to a parathyroid adenoma. The patient's serum biochemistry normalised after removal of the adenoma. The association of adrenal myelolipoma with primary hyperparathyroidism has been reported in the literature only once previously. Although unconfirmed by genetic studies this association may possibly represent an unusual variation of the multiple endocrine neoplasia type 1 syndrome. ( info) |
5/2777. Undetectable urinary free cortisol concentrations in a case of Cushing's disease. Measurement of the 24-h urinary free cortisol is a valuable screening test of endogenous hypercortisolism and, although false positive results may occur in a few situations, for example endogenous depression, false negative results are unusual. We report a case of a 48-year-old lady with pituitary-dependent Cushing's disease, whose 24-h urinary free cortisol excretion was consistently undetectable in association with increased plasma and salivary cortisol concentrations and reduced dexamethasone suppressibility. The patient had chronic renal impairment (creatinine clearance 21 ml/min) as a consequence of hypertension, despite only modestly increased urea and creatinine concentrations. Urinary free cortisol measurements must be interpreted with caution in patients with renal impairment. ( info) |
6/2777. Acute renal failure from multiple myeloma precipitated by ACE inhibitors. Renal failure in multiple myeloma can be precipitated during hemodynamic perturbances of renal blood flow, as seen secondary to volume depletion, radiocontrast dye, and nonsteroidal anti-inflammatory agents. We report two cases of acute renal failure that developed suddenly after initiation of angiotensin-converting enzyme (ACE) inhibitor, both with biopsy-proven cast nephropathy. ACE inhibitors may contribute to the intratubular light chain cast formation and acute "myeloma kidney" in susceptible patients. ( info) |
| There are an increasing number of reports about unusual causes of peritonitis in peritoneal dialysis (PD) patients. The Propionibacteria species is a microorganism that is a normal skin flora. Under the presence of certain risk factors, it may produce serious infections. patients at risk of having Propionibacteria sp infections have malignancy, diabetes mellitus, foreign bodies, or immunodeficiency. We describe a PD-associated peritonitis in a 51-year-old woman that was caused by Propionibacteria sp. This patient's risk factors for developing Propionibacteria sp peritonitis include a history of crest syndrome, malignancy of the breast, and recent catheter surgery. To our knowledge, this is the first case of a PD-associated peritonitis caused by Propionibacteria sp reported in the literature. ( info) |
8/2777. Severe cardiac dysrhythmia in patients using bromocriptine postpartum. Used worldwide since 1980 for the prevention of breast engorgement in the puerperium, in 1994 bromocriptine mesylate was withdrawn from the American market as an agent suitable for ablactation. The relevant recommendation of the food and Drug Administration rested on case reports that described severe vasospastic reactions among users of the drug. Some patients so affected suffered stroke, intracranial bleeding, cerebral edema, convulsions, myocardial infarction, and puerperal psychosis. More recently, it has been suggested that the side effects of the drug may also include circulatory collapse secondary to cardiac dysrhythmia. This report describes two additional cases in this category. The antepartum clinical evaluation of these women suggested that they were predisposed to arrhythmias. ( info) |
9/2777. University of Miami Division of Clinical pharmacology Therapeutic Rounds: ischemic renal disease. Ischemic renal disease (IRD) is defined as a significant reduction in glomerular filtration rate and/or loss of renal parenchyma caused by hemodynamically significant renal artery stenosis. IRD is a common and often overlooked clinical entity that presents in the setting of extrarenal arteriosclerotic vascular disease in older individuals with azotemia. IRD is an important cause of chronic renal failure and end-stage renal disease (ESRD), and many patients with a presumed diagnosis of hypertensive nephrosclerosis may actually have undiagnosed ischemic nephropathy as the cause of their ESRD. The primary reason for establishing the diagnosis of IRD is the hope that correction of a renal artery stenosis will lead to improvement of renal function or a delay in progression to ESRD. There are six typical clinical settings in which the clinician could suspect IRD: acute renal failure caused by the treatment of hypertension, especially with angiotensin-converting enzyme inhibitors; progressive azotemia in a patient with known renovascular hypertension; acute pulmonary edema superimposed on poorly controlled hypertension and renal failure; progressive azotemia in an elderly patient with refractory or severe hypertension; progressive azotemia in an elderly patient with evidence of atherosclerotic disease; and unexplained progressive azotemia in an elderly patient. It is important for the clinician to identify IRD, because IRD represents a potentially reversible cause of chronic renal failure in a hypertensive patient. ( info) |
| We describe two adolescent boys with white coat hypertension. Both patients had significantly high blood pressure documented on more than three occasions at clinic. No cause for hypertension or target organ damage was demonstrated. Twenty-four-hour mean ambulatory blood pressure values were normal for height and sex, which led to the diagnosis. ( info) |