CASE 17349 Published on 08.07.2021

Male patient with malignant hypertension

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Anagha P. Parkar MD1,2; Miraude E.A.P.M. Adriaensen MD, PhD3

1. Radiology Department, Haraldsplass Deaconess Hospital, Postboks 6165 Posterminalen, 5892 Bergen, Norway.

2. Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Postboks 7804, 5021 Bergen, Norway.

3. Department of Radiology, Zuyderland Medical Center, Henri Dunantstraat 5, 6419 PC Heerlen, the Netherlands.

Patient

50 years, male

Categories
Area of Interest Abdomen, Arteries / Aorta, Vascular ; Imaging Technique CT, CT-Angiography
Clinical History

Male patient in his 50s with malignant hypertension, high levels of normetanephrine. Patient recently treated with angiotensin-converting enzyme inhibitors, and admitted with an acute rise in renin levels. Routine CT of the abdomen was requested.

Imaging Findings

Fibromuscular dysplasia (FMD)  is a rare disease. It is characterised by a segmental arterial disease, which is neither atheromatous nor inflammatory. The exact cause is unknown. It affects smaller and to medium-sized arteries. Most commonly affected are renal arteries, second common are carotid arteries. However, it can occur in any artery in the body.

If symptomatic, patients often present with hypertension and symptoms related to hypertension (headaches, dizziness etc.). Some patients may also be asymptomatic, and the findings may be incidental. Up to 80-90% of cases are female, it is important not to “overlook” this diagnosis in male patients.

Discussion

In the presented case the symptoms were hypertension and the explanation for this is seen in the left renal artery with a beaded appearance of the proximal artery. There are also aneurysms in the coeliac trunk and a dissection proximally in the coeliac trunk.

This should alert radiologists to the diagnosis of fibromuscular dysplasia with multivessel involvement [1]. Previously, this entity was called “visceral fibromuscular dysplasia.  It has to be differentiated from simple renal arterial fibromuscular dysplasia, as the patient should be examined for carotid pathology, as carotid pathology may predispose to strokes [1]. Patients are treated with anti-platelets and anti-hypertensive drugs as a rule and may have to undergo endovascular intervention in more severe cases [1]. Another important differential diagnosis is visceral artery dissection with normal-appearing arteries (VADNA)“[2]. This is a disease that mainly affects abdominal vessels and presents often with abdominal or flank pain, and this could have been the case if there had been no renal artery affection.

Differential Diagnosis List
Pheochromocytoma
Fibromuscular dysplasia with multivessel involvement.
Right-sided renal artery stenosis
Visceral artery dissection with normal-appearing arteries
Kidney tumour
Final Diagnosis
Fibromuscular dysplasia with multivessel involvement.
Case information
URL: https://www.eurorad.org/case/17349
DOI: 10.35100/eurorad/case.17349
ISSN: 1563-4086
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