Medical Image of the Week: Hypertensive Emergencies

Figure 1. Head CT scan showing basal ganglia hemorrhage (red arrow) and posterior reversible encephalopathy syndrome (green arrows).

A 39-year-old man had sudden onset of left sided hemiparesis, headache and nausea. He had a history of untreated hypertension and diabetes mellitus. On initial evaluation by emergency medical services, his blood pressure was 270/170 mm Hg. Shortly after admission, he suffered a generalized seizure treated with levetiracetam. His labs were remarkable for a creatinine of 4.4 mg/dL and microscopic hematuria. His head CT findings are consistent with two simultaneous neurological hypertensive emergencies – intracranial hemorrhage of the basal ganglia and posterior reversible encephalopathy syndrome (PRES) (Figure 1) (1). PRES is areas of edema seen as multiple cortico-subcortical areas of hyperintense (white) signal involving the occipital and parietal lobes bilaterally and pons. His renal failure likely represents a third hypertensive emergency. His blood pressure was lowered into the 140/90 range within 2 hours by nicardipine infusion and intravenous labetalol boluses. He subsequently suffered worsening mental status and unilateral pupillary dilation and underwent emergent craniotomy. He survived but is currently past 50 days in the hospital.

Robert A. Raschke MD

Critical Care Medicine

Banner University Medical Center at Phoenix

Phoenix, AZ USA

Reference

1. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000 Jul 29;356(9227):411-7. [CrossRef] [PubMed]

Cite as: Raschke RA. Medical image of the week: hypertensive emergencies. Southwest J Pulm Crit Care. 2017;15(4):147. doi: https://doi.org/10.13175/swjpcc111-17 PDF

Medical Image of the Week: Coral Reef Aorta

Figure 1. Coronal (A) and lateral (B) thoracic CT in soft tissue windows showing the coral reef calcification (arrows).

A 52-year-old woman with no past medical history presented to the emergency department with signs and symptoms concerning for pneumonia. Chest x-ray showed incidental findings of a calcified aortic mass. Subsequently, a follow up computed tomography scan (CT) was obtained which showed coral reef aorta (Figure 1). On physical examination, vital signs were only significant for mildly elevated blood pressure to 146/62 mmHg. She also had normal and equal pulses and pressures throughout all 4 extremities. In retrospect, patient had complaints of bilateral lower extremity claudication on strenuous exercise.

Coral reef aorta, a rare condition that was first described in 1984 by Qvarfordt et al. (1) is characterized by an eccentric, heavily calcified polypoid lesion and stenosis of the juxtarenal and suprarenal aorta. The rock-hard, irregular, gritty, whitish surface of the calcification strongly resembled a coral reef. The most common presentation is severe hypertension and intermittent claudication. Magnetic resonance angiogram (MRA) and CT have the ability to diagnose and appreciate the extent of this phenomenon (2).

Lance Eberson MS¹ and Sehem Ghazala MD²

¹College of Medicine and ²Department of Internal Medicine

University of Arizona

Tucson, Arizona, USA

References

1. Qvarfordt PG, Reilly LM, Sedwitz MM, Ehrenfeld WK, Stoney RJ. "Coral reef" atherosclerosis of the suprarenal aorta: a unique clinical entity. J Vasc Surg. 1984 Nov;1(6):903-9. [CrossRef] [PubMed]
2. Kopani K, Liao S, Shaffer K. The Coral Reef Aorta: Diagnosis and Treatment Following CT. Radiol Case Rep. 2016 Oct 4;4(1):209. eCollection 2009. [CrossRef] [PubMed] 

Cite as: Eberson L, Ghazala S. Medical image of the week: coral reef aorta. Southwest J Pulm Crit Care. 2017:15(1):49. doi: https://doi.org/10.13175/swjpcc080-17 PDF

Medical Image of the Week: Renal Infarction

Figure 1. Contrast enhanced CT of the abdomen showing the majority of the right kidney infarcted with some preservation of the superior pole. 

A 79-year-old woman with past medical history of persistent atrial fibrillation not on anticoagulation, coronary artery disease, hypertension, diabetes, and hyperlipidemia presented with right flank pain accompanied by nausea and vomiting for two days. Laboratory studies showed leukocytosis with creatinine of 1.2. Urinalysis was negative for signs of infection and red blood cells. However, despite being on analgesic, she continued to have flank pain. The patient subsequent underwent CT scan of the abdomen and pelvis the next day, which showed that the majority of the right kidney was infarcted. Interestingly, there were two right-sided renal arteries and a thrombus was seen in the inferior main right renal artery. The superior pole of the right kidney was preserved as a result of the patent accessory renal artery. Due to delayed presentation of more than 48 hours after onset of pain, the tissue could not be re-vascularized by vascular surgery. Her renal function remained intact and her flank pain gradually improved. 

Acute renal infarction is difficult to diagnose as it is mimicked by more commonly seen causes such as pyelonephritis and nephrolithiasis. Pain in the unilateral flank and/or abdomen is the hallmark presenting feature, however nausea, vomiting, and fever are also common. New or increasingly severe hypertension is found in approximately half of acute renal infarction diagnosis, a sign that should raise clinical suspicion in similar clinical scenario. Proteinuria is another feature that may be present on urinalysis. Creatinine elevation consistent with acute kidney injury (AKI) occurs in approximately 30-40% of cases (1). Leukocytosis is commonly seen in as many as three-quarters of patients with renal infarct. The most common laboratory finding in renal infarction is elevation of LDH, although this is nonspecific and does not necessarily aid in specific diagnosis (2). Diagnosis is usually made through contrast enhanced CT abdomen, however angiography may also be used.

Our patient also had two renal arteries supplying her right kidney, allowing for the superior pole of her renal parenchyma to be spared and thus her kidney function. The kidney tolerates ischemia for approximately 12 hours, making early diagnosis paramount. In patient’s such as the one described here that involves all or majority of one kidney, embolectomy is recommended because of favorable outcomes in prior studies (3). In summary, the challenge of early diagnosis of renal infarction lies in the recognition of nonspecific clinical symptoms and signs in an already rare occurrence. Recognizing these signs within hours of presentation may be the difference between viable renal tissue and death of a kidney. Keeping a high suspicion in patients with atrial fibrillation will also aid in early diagnosis.

Jessica August MD and Jennifer J Huang DO

Department of Internal Medicine

University of Arizona

Tucson, AZ

References

1. Bae EJ, Hwang K, Jang HN, Kim MJ, Jeon DH, Kim HJ, Cho HS, Chang SH, Park DJ. A retrospective study of short- and long-term effects on renal function after acute renal infarction. Ren Fail. 2014;36(9):1385-9. [CrossRef] [PubMed]
2. Antopolsky M, Simanovsky N, Stalnikowicz R, Salameh S, Hiller N. Renal infarction in the ED: 10-year experience and review of the literature. Am J Emerg Med. 2012;30(7):1055-60. [CrossRef] [PubMed]
3. Tsai SH, Chu SJ, Chen SJ, Fan YM, Chang WC, Wu CP, Hsu CW. Acute renal infarction: a 10-year experience. Int J Clin Pract. 2007;61(1):62-7. [CrossRef] [PubMed]

Reference as: August J, Huang JJ. Medical image of the week: renal infarction. Southwest J Pulm Crit Care. 2015;10(4):195-6. doi: http://dx.doi.org/10.13175/swjpcc023-15 PDF

Medical Image of the Week: Acute Aortic Dissection

Figure 1. Acute aortic dissection presenting with the following radiographic signs: rightward deviation of the trachea (red arrow); left apical pleural capping (blue arrow); aortic “double-calcium” sign (between white arrows); depression of the left bronchus (purple arrow); pleural effusion (green arrow); widened mediastinum and loss of the aorto-pulmonary window (not labeled).

The patient was a 75 year old woman with a past medical history of uncontrolled hypertension and recent type-A aortic dissection post graft repair. She presented with a sudden onset of sharp mid-back pain which awoke her from sleep. In the emergency room a chest x-ray revealed numerous features consistent with a de novo type B aortic dissection which was ultimately confirmed by magnetic resonance angiography of the chest and abdomen. This dissection extended from the left subclavian artery to the right renal artery. There was no evidence of end-organ mal-perfusion and the patient was medically managed by way of blood pressure control.

Seth Assar, MD; Thien Vo, MD; Jarrod Mosier, MD

The University of Arizona College of Medicine, Tucson, Arizona

Reference

Bansal V, Lee J, Coimbra R. Current diagnosis and management of blunt traumatic rupture of the thoracic aorta. J Vasc Bras. 2007;6(1):64-7. [CrossRef]

Reference as: Assar S, Vo T, Mosier J. Medical image of the week: acute aortic dissection. Southwest J Pulm Crit Care. 2014;8(4):234. doi: http://dx.doi.org/10.13175/swjpcc039-14 PDF