Cases reported "Hypertension"

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1/63. Decreases in blood pressure and sympathetic nerve activity by microvascular decompression of the rostral ventrolateral medulla in essential hypertension.

    BACKGROUND: Neurovascular compression of the rostral ventrolateral medulla, a major center regulating sympathetic nerve activity, may be causally related to essential hypertension. Microvascular decompression of the rostral ventrolateral medulla decreases elevated blood pressure. CASE DESCRIPTION: A 47-year-old male essential hypertension patient with hemifacial nerve spasms exhibited neurovascular compression of the rostral ventrolateral medulla and facial nerve. Microvascular decompression of the rostral ventrolateral medulla successfully reduced blood pressure and plasma and urine norepinephrine levels, low-frequency to high-frequency ratio obtained by power spectral analysis, and muscle sympathetic nerve activity. CONCLUSIONS: This case suggests not only that reduction in blood pressure by microvascular decompression of the rostral ventrolateral medulla may be mediated by a decrease in sympathetic nerve activity but also that neurovascular compression of this area may be a cause of blood pressure elevation via increased sympathetic nerve activity.
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2/63. prevalence of mild apparent mineralocorticoid excess in Mennonites.

    We have studied an unusual patient with mild low-renin hypertension due to a homozygous mutation in the HSD11B2 gene (PNAS 95:10200-10205, 1998). The patient came from an inbred Mennonite family, and though the mutation identified her as an AME patient, she had a normal birth weight and did not demonstrate the typical features of AME, such as hypokalemic alkalosis, low birth weight, failure to thrive, poor growth, and in many cases nephrocalcinosis. Biochemically, typical patients with AME have abnormal cortisol metabolites and an exceedingly diminished ability to convert [11-3H]cortisol to cortisone. In this patient with mild AME, the conversion of cortisol to cortisone was 58% compared to 0 to 6% in typical AME patients, while the normal conversion is 90 to 95%. Molecular analysis of the HSD11B2 gene of this patient showed a homozygous mutation in codon 227 (P227L). We studied this Mennonite population for the prevalence of the P227L mutation. Our hypothesis was that this mild form of AME would be prevalent in the somewhat inbred Mennonite population to which the patient belongs. Our proposed study was 1) to determine if there are other cases of this mild form of AME, and 2) to establish the heterozygote frequency of the mutation in the Mennonites. RESULTS: We did not detect any additional cases of mild AME. We detected 15 carriers of the P227L mutation out of 445 Mennonites, resulting in a heterozygote frequency of 0.03. CONCLUSION: Since this is an inbred population, the chance of two heterozygotes marrying would be 0.001, which is 1 in 1000 people. This population is known to have large families and therefore the possibility of having an affected child is high. The population consists of 2000 members and we have discovered one affected patient. Thus, there might be one other patient in this population.
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3/63. syncope caused by nonsteroidal anti-inflammatory drugs and angiotensin-converting enzyme inhibitors.

    A 85-year-old woman with diabetes mellitus and prior myocardial infarction was transferred to the emergency room with loss of consciousness due to marked bradycardia caused by hyperkalemia. The T wave during right ventricular pacing was tall and tent-shaped while the concentration of serum potassium was high, and its amplitude during pacing was decreased after correction of the serum potassium level. Simultaneously with the correction, normal sinus rhythm was restored. The cause of hyperkalemia was considered to be several doses of loxoprofen, a nonsteroidal anti-inflammatory drug (NSAID), prescribed for her lumbago by an orthopedic specialist, in addition to the long-term intake of imidapril, an angiotensin-converting enzyme inhibitor (ACEI), prescribed for her hypertension by a cardiologist. This case warns physicians that the combination of NSAID and ACEI can produce serious side effects in aged patients who frequently suffer from hypertension, diabetes mellitus, ischemic heart disease, and degenerative joint disease.
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4/63. brain stem stroke causing baroreflex failure and paroxysmal hypertension.

    BACKGROUND: Paroxysmal neurogenic hypertension has been associated with a variety of diseases affecting the brain stem but has only rarely been reported after brain stem stroke. The mechanism is thought to involve increased sympathetic activity and baroreflex dysfunction. We undertook microneurographic recordings of muscle sympathetic nerve activity (MNSA) during beat-to-beat blood pressure (BP) monitoring to investigate this hypothesis. CASE DESCRIPTION: We investigated a 75-year-old woman who developed paroxysmal hypertension (BP 220/110 mm Hg) after a large left-sided medullary infarct. The paroxysms were triggered by changes in posture and were accompanied by tachycardia, diaphoresis, and headache. serum catecholamines were substantially increased (norepinephrine level, 23.9 nmol/L 9 days after stroke; normal level, <3.8 nmol/L), and heart rate variability, measured by spectral analysis, was decreased in both low- and high-frequency domains (0.04 and 0.06 ms(2), respectively; normal level, 0.14 /-0.02 ms(2)). MNSA was increased in frequency (61 bursts per minute; normal level, 34 /-18 bursts per minute), and the burst amplitude was not inversely related to diastolic BP. BP and MNSA responses to cold pressor and isometric handgrip stimuli were intact. CONCLUSIONS: Extensive unilateral infarction of the brain stem in the region of the nucleus tractus solitarius may result in partial baroreflex dysfunction, increased sympathetic activity, and neurogenic paroxysmal hypertension.
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5/63. Evidence for specialized atrioventricular conduction in hyperkalemia.

    A patient who had chronic coarse atrial fibrillation developed severe hyperkalemia accompanied by total loss of fibrillatory waves while an irregularly irregular ventricular rhythm persisted. Correction of hyperkalemia resulted in prompt return of coarse atrial fibrillation. This sequence of events renders strong support to direct atrioventricular conduction through the specialized internodal tracts.
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6/63. A case of hyperreninemic hypertension after extracorporeal shock-wave lithotripsy.

    A 53-year-old male was found to have hypertension caused by the significant secretion of renin from an atrophic left kidney. He had undergone extracorporeal shock-wave lithotripsy (ESWL) for left renal lithiasis 11 years previously. A renal dynamic study with 99mTc-diethylenetriaminepentaacetic acid (DTPA) indicated that the rate of renal excretion and uptake was decreased in the left kidney and normal in the right kidney. Renal angiography demonstrated a normal right renal artery and a small but nonstenotic left renal artery. The ratio of PRA in the left renal vein to that in the right renal vein was 1.7. blood pressure could be lowered to the range of 140-150/80-90 mmHg with imidapril, an ACE inhibitor. ESWL may cause hypertension via the well-known Page kidney effect. In this case, the kidney, atrophic probably due to ESWL, released a significant amount of renin.
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7/63. Giant negative T waves during interferon therapy in a patient with chronic hepatitis c.

    interferon-alpha (IFN-alpha) has been widely used for treatment of chronic hepatitis c in japan. In general, cardiovascular adverse reactions are rare in association with IFN-alpha therapy. Here, a 64-year-old man with chronic active hepatitis c complained of fatigue, palpitation and depression, and developed atrial fibrillation with prominent negative T waves during IFN-alpha therapy. Echocardiogram showed septal and apical hypertrophy. Three days after discontinuation of IFN-alpha, subjective symptoms and atrial fibrillation subsided. It is unclear whether or not IFN-alpha induced the giant negative T waves with apical hypertrophy. We might observe the developing course of hepatitis c virus (HCV)-related myocardial hypertrophy by chance. Cardiovascular toxicity should be carefully monitored during IFN-alpha therapy even in patients with minor cardiac disease, such as premature ventricular contracture (PVC) and mild hypertension.
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8/63. A possible explanation for the frequent concomitance of arterial hypertension and multiple renal arteries.

    In more than 20% of subjects, at least one kidney is found to be supplied by more than one artery arising from the aorta. This aberrant renovascular anatomy has been reported in the literature to occur in up to 80% of patients who suffer from essential hypertension. Predominant numbers of the so-called 'accessory' vessels are longer and narrower than the segmental arteries arising in the main renal artery. As a result (in accordance with Poiseuille's law of fluid flow), the renal segments supplied by these 'accessory' vessels may have lower levels of blood pressure than the remainder of the parenchyma, thereby increasing the renin secretion. This hypothesis could be significant in terms of finding a causal treatment for a disorder induced by such a mechanism. We first review the literature in which the frequency of these vascular anomalies in normotensive and hypertensive patients is described, and then advance a hypothesis explaining the frequent incidence of essential hypertension in these subjects, as well as the ramifications of this phenomenon.
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9/63. Pseudomembranous colitis without diarrhea presenting clinically as acute intestinal pseudo-obstruction.

    Pseudomembranous colitis usually presents with diarrhea in a clinical setting of recent antibiotic use. It is uncommon to see it as a cause of obstipation and colonic pseudo-obstruction. We report an unusual case of an elderly woman with hypertension, congestive heart failure, chronic obstructive pulmonary disease, chronic renal insufficiency, and diabetes mellitus, who was admitted with fever, abdominal pain, and distension without diarrhea. She presented with decreased stool frequency and obstipation. She did not respond to conservative management. colonoscopy revealed a picture of pseudomembranous colitis, and clostridium difficile toxin was positive. She responded well to metronidazole therapy.
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10/63. pheochromocytoma.

    Causes of hypertension that are amenable to surgical treatment constitute a very small but potentially important segment of the hypertensive population. These causes (which constitute frequently asked questions for medical students) include coarctation of the aorta, aldosterone and corticosteroid-producing tumors of the adrenal glands, lesions producing decreased renal blood flow, and pheochromocytoma. This latter tumor is quite uncommon, with a frequency of roughly one per million, but often produces dramatic hypertensive episodes. Due to its rarity, physicians in practice may not consider the diagnosis and appropriately evaluate the patient. We present the case histories of three patients with pheochromocytoma who demonstrate important features of this disease. Diagnostic evaluation and principles of treatment will be discussed.
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