44 A 28-Year-Old Female With Difficult-to-Control Hypertension


Case 44

A 28-Year-Old Female With Difficult-to-Control Hypertension



Seth Politano, Eric Hsieh



A 28-year-old female presents to you to establish care. She has a previous history of high blood pressure on amlodipine 10 mg daily, atenolol 100 mg daily, and lisinopril 40 mg daily. She has no other medical problems, but her family history is significant for type 2 diabetes mellitus in her mother, who uses insulin. Review of systems is positive for fatigue, intermittent headaches, diaphoresis, and palpitations. Vital signs reveal a blood pressure of 180/110 mm Hg in the right arm, 182/110 mm Hg in the left arm, and a pulse rate of 104/min. Her physical exam is otherwise normal.




What are the causes of secondary hypertension? What clues should you look for on history or physical exam?


Table 44.1 summarizes the causes of secondary hypertension and key clinical findings.



Step 2/3


Clinical Pearl


In patients with suspected secondary hypertension, testing should be performed as guided by clinical suspicion for causes, instead of a battery of all possible tests.



Step 2/3


Clinical Pearl


Medications and substances that can contribute to hypertension include oral contraceptives, decongestants, nonsteroidal antiinflammatory drugs, thyroid supplementation, corticosteroids, cyclosporine, erythropoietin, triptans, ergotamine, alcohol, cocaine, methamphetamine, and phencyclidine (PCP) use.



On further questioning, the patient reveals that she gets “anxious” frequently throughout the day, worries about this occurring, and this prevents her from performing her job to previous standards.



TABLE 44.1


Causes of Secondary Hypertension and Key Physical Exam/Historical Findings








































Condition Hints to Obtain from History/Exam/Workup
Hyperaldosteronism Hypokalemia and metabolic alkalosis.
Pheochromocytoma Palpitations, headache, diaphoresis, anxiety.
Cushing’s syndrome Dorsocervical fat pad (“buffalo hump”), central obesity, moon facies, striae of the abdomen and thighs. Fatigue, easy bruising, myopathy, amenorrhea. Use of corticosteroids, smoker, and/or chronic lung disease suggesting an ectopic source.
Chronic kidney disease Elevated potassium, serum creatinine, low serum bicarbonate, uremic symptoms.
Renal artery stenosis Patient with atherosclerotic risk factors and with other atherosclerotic diseases (coronary artery disease, cerebral vascular accident, peripheral vascular disease). Renal bruit. Hypokalemia. Can present with sudden pulmonary edema and acute renal failure especially after starting angiotensin-converting enzyme in bilateral renal artery stenosis.
Fibromuscular dysplasia Young female with headache, pulsatile tinnitus. Epigastric, renal, carotid bruits.
Coarctation of the aorta Systolic blood pressure is >20 mm Hg higher in arms compared to legs. Absent or delayed femoral pulses. Chest radiograph with rib notching and/or “3” sign.
Thyroid diseases (both hyperthyroidism and hypothyroidism) Fatigue, weight gain/loss, tremor, tachycardia/bradycardia, heat/cold intolerance, menstrual irregularities, bowel irregularities, warm/dry skin.
Obstructive sleep apnea Excessive daytime somnolence, large neck circumference, snoring and apneic events reported by partner.
Acromegaly Visual changes, fatigue, headaches. Observed change in appearance including jaw enlargement and coarse facial features. Change in hat/shoe/glove/ring size. Can have visual disturbances, secondary diabetes, sleep apnea.
Hyperparathyroidism Fatigue, osteoporosis, nephrolithiasis, abdominal pain, constipation, nausea, anorexia, altered mental status, lethargy.


Does this finding increase your suspicion for any causes of the patient’s hypertension?


Drugs of abuse (including cocaine or methamphetamine) as well as withdrawal from certain medications (i.e., alcohol and benzodiazepines) should be considered as they can cause both hypertension and anxiety. In addition, medical causes such as pheochromocytoma should be considered in this setting as they induce anxiety as well as hypertension.



The patient denies the use of any illicit drugs or alcohol. Given her clinical findings, including headache, diaphoresis, palpitations, resistant hypertension, and anxiety disorder, you are concerned for pheochromocytoma.



What is the epidemiology of pheochromocytomas?


Pheochromocytomas are rare tumors of the adrenal medulla that derive from neural crest cells. Incidence ranges from 1 to 10 patients per million. They are present in from 0.1 to 1% of hypertensive patients. They usually present in patients between 30 and 40 years of age.



What is the pathophysiology of the disease?


Chromaffin cells can produce norepinephrine (most common), epinephrine, dopamine (more common with malignant tumors), and other substances such as vasoactive intestinal peptide and somatostatins. These are responsible for the clinical findings in patients and the variability of clinical presentation.



Step 1/2/3


Basic Science/Clinical Pearl


There are other tumors that arrive from the same neural crest, such as neuroblastomas and gangliomas, and therefore may present with symptoms similar to those of pheochromocytoma.



What are the risk factors for pheochromocytoma? What other conditions are associated with pheochromocytoma?


Risk factors for pheochromocytoma include a family history of a genetic syndrome known to be associated with the disease. Table 44.2 lists disease associations with pheochromocytoma.



TABLE 44.2


Disease Associations With Pheochromocytoma












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Jun 15, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on 44 A 28-Year-Old Female With Difficult-to-Control Hypertension

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Condition Clinical Hints/Findings
MEN IIA Pheochromocytoma, hyperparathyroidism, and medullary carcinoma of the thyroid.
MEN IIB