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Clinicopathologic Conference: A 70‐Year‐Old Male With Hypertensive Emergency

Four months prior to presentation to the rheumatology office, the patient was admitted to the hospital with severe, persistent dental pain around the mandibular right third molar for which he had a tooth extraction. The pain continued despite the procedure. Three days later, the patient was readmitted with 20 minutes of vision loss in the left eye and 3 days of constant occipital headache radiating to the posterior neck. He was febrile with a temperature of 101°F, blood pressure reading of 154/80 mm Hg, pulse rate of 90 beats per minute, and oxygen saturation of 94% on room air. There was a concern for meningitis due to the presence of fever and occipital headache. Endocarditis was suspected due to the recent dental surgery. However, CT images of the head and neck, magnetic resonance imaging (MRI) of the brain, and CT images of the maxillofacial area with contrast were unrevealing. Evaluation for infectious disease including blood cultures and a transthoracic echocardiogram did not suggest infection. The lumbar puncture performed prior to antibiotic administration showed a normal cell count and glucose level, but a mildly elevated level of protein at 47.4 mg/dl (reference 15– 45 mg/dl). Nonetheless, while awaiting Gram stain and culture, the patient was broadly treated with vancomycin, ceftriaxone, and ampicillin. Intravenous dexamethasone at a dosage of 10 mg every 6 hours for 2 days was also given as part of the empirical treatment due to suspicion of bacterial meningitis. The patient was discharged from the hospital in stable condition with improvement of headache and neck pain. One month prior, the patient was hospitalized for hypertensive emergency complicated by pulmonary edema and hypoxic respiratory failure. His blood pressure reading at the time was 193/100 mm Hg. His presentation was thought to be due to exacerbation of chronic obstructive pulmonary disease (COPD). Therefore, he received antihypertensive medication, intravenous diuretic, intravenous albuterol, and ipratropium nebulizer treatments. As part of the treatment for COPD exacerbation, the patient also received 60 milligrams of intravenous solumedrol twice daily. No further imaging was performed as the patient’s blood pressure and respiratory symptoms improved on the fifth day of hospitalization. He was discharged in stable condition. Two weeks after discharge, the patient presented to his primary care physician with recurrence of symptoms of occipital headache and mandibular toothache. Despite receiving antihypertensive medications, he remained hypertensive with a blood pressure reading of 180/100 mm Hg. He denied any pulmonary complaints. A renal ultrasound with Doppler was initially ordered to exclude renal artery stenosis as a cause of his uncontrolled hypertension, but the renal arteries were not visualized due to extensive bowel gas. A CT of the abdomen and pelvis with contrast was subsequently performed. Imaging showed concentric wall thickening of the visualized descending thoracic aorta, splenic artery, portions of the abdominal aorta, the common iliac arteries, and renal artery branches to the right kidney along with ischemic changes of the right renal parenchyma (Figures 1 and 2). Based on the extent of the vasculature involved, systemic vasculitis was suspected. After discussion with the rheumatology department, additional laboratory data were ordered (Table 1), and the patient was initiated on a regimen of 60 mg of prednisone daily by his primary care physician. During the rheumatology office visit, the patient reported overall improvement since prednisone initiation 2 weeks ago. When asked about his previous major complaint, he revealed that