A 22-year-old man comes to the clinic due to frequent headaches. He plays football on weekends but over the last 3 months has noticed a dry cough and decreased exercise tolerance due to shortness of breath. The patient has also had lower extremity swelling and says that his face feels "puffy." He is a lifetime nonsmoker and does not use alcohol or illicit drugs. The patient's mother was diagnosed with hypertension at age 45 and takes 2 antihypertensive medications; his father is healthy. The patient has no siblings. Blood pressure is 180/102 mm Hg in the right arm and 183/99 mm Hg in the left and pulse is 85/min and regular. BMI is 24 kg/m². Upper and lower extremity pulses are equal. Bilateral lower extremity edema is present. The remainder of the physical examination is normal. ECG shows normal sinus rhythm. Which of the following is the most likely cause of this patient's condition? A)Adrenal cortical tumor B)Adrenal medullary tumor C)Congenital narrowing of the aorta D)Renal artery stenosis E)Renal parenchymal disease

Question

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Explanation: 11ec2b69_c11d_5c7d_8f63_21ab5e2885eb_MD0005_00 The following clinical features suggest a secondary cause of hypertension: Onset at age <30 Acute blood pressure increase in a patient with previously stable values Evidence of end-organ damage (eg, retinal hemorrhages, heart failure) Severe or resistant hypertension (ie, uncontrolled despite an appropriate 3-drug regimen) Renal parenchymal disease (eg, glomerulonephritis, vesicoureteral reflux) is a common cause of secondary hypertension in young adults and is the likely cause in this patient. Glomerulonephritis may develop subacutely and may be associated with variable degrees of proteinuria. Hypertension is more common in glomerular disease with a nephritic presentation (ie, hematuria with less prominent proteinuria) but can also occur with a nephrotic presentation characterized by proteinuria >3.5 g/day and edema (eg, facial puffiness, lower extremity swelling). In both cases, hypertension is likely caused by increased renal sodium absorption due to resistance to atrial natriuretic peptide and elevated activity of collecting tubule sodium-potassium pumps. (Choice A) Adrenal cortical tumors can cause secondary hypertension as a manifestation of Cushing syndrome or hyperaldosteronism. However, Cushing syndrome usually causes characteristic physical features, and hyperaldosteronism rarely causes edema due to aldosterone escape. Both conditions are uncommon in young adults. characteristic physical features aldosterone escape (Choice B) Adrenal medullary pheochromocytoma secretes catecholamines and usually presents with hypertension associated with episodic headaches, flushing, sweating, and tachycardia, which are absent in this patient. In addition, edema and decreased exercise tolerance would not be expected. (Choice C) Coarctation of the aorta typically presents in childhood, not young adulthood, with upper extremity hypertension that may be accompanied by headache, epistaxis, and symptoms of lower extremity claudication. Equal upper and lower extremity pulses make coarctation unlikely, and edema would not be expected. (Choice D) Renal artery stenosis due to atherosclerosis is most often seen in patients age >65 and would be very unusual in a young man. Fibromuscular dysplasia is a potential cause of renal artery stenosis in young patients but overwhelmingly affects female patients (~90% of cases). Educational objective: Renal parenchymal disease is an important cause of secondary hypertension in adults age <30. Glomerulonephritis, with either a nephritic or nephrotic presentation, can lead to secondary hypertension due to increased renal sodium reabsorption. References: Diagnosis of secondary hypertension: an age-based approach. (http://www.ncbi.nlm.nih.gov/pubmed/21166367)

A 22-Year-Old Man Comes to the Clinic Due to Frequent