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  #1  
Old 08-03-2011
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Sphygmomanometer Female with Renal Hypertension

A 45-year-old woman has had increasing malaise for the past year. On physical examination her blood pressure is 265/150 mm Hg. Laboratory studies show a plasma renin activity of 9 ng/mL/hr. She then suffers a "stroke" with a right basal ganglia hemorrhage and dies. At autopsy the kidneys are bilaterally small with granular surfaces. Microscopically they show hyperplastic arteriolosclerosis with fibrinoid necrosis, petechial hemorrhages, and microinfarcts in the cortices. Which of the following conditions is most likely to be her underlying cause of death?

A Diabetes mellitus, type II
B Fibromuscular dysplasia
C Factor V Leiden mutation
D Analgesic abuse
E Diffuse scleroderma
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  #2  
Old 08-03-2011
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analgesic abuse..
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  #3  
Old 08-03-2011
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hyperplastic arteriolosclerosis = Malignant hypertension!

Could be B or E...B is far more frequent than E, but in this case BOTH kidneys are small...so I think is E)
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  #4  
Old 08-03-2011
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Idea!

Quote:
Originally Posted by bebix View Post
hyperplastic arteriolosclerosis = Malignant hypertension!

Could be B or E...B is far more frequent than E, but in this case BOTH kidneys are small...so I think is E)
But for sclerodema there are no pointers like Raynauds phenomenon, sclerodactyly, esophageal dysmotility

I think its Fibromuscular dysplasia
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  #5  
Old 08-03-2011
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Diffuse scleroderma, not sure
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  #6  
Old 08-04-2011
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Quote:
Originally Posted by dr_lizard View Post
A 45-year-old woman has had increasing malaise for the past year. On physical examination her blood pressure is 265/150 mm Hg. Laboratory studies show a plasma renin activity of 9 ng/mL/hr. She then suffers a "stroke" with a right basal ganglia hemorrhage and dies. At autopsy the kidneys are bilaterally small with granular surfaces. Microscopically they show hyperplastic arteriolosclerosis with fibrinoid necrosis, petechial hemorrhages, and microinfarcts in the cortices. Which of the following conditions is most likely to be her underlying cause of death?

A Diabetes mellitus, type II
B Fibromuscular dysplasia
C Factor V Leiden mutation
D Analgesic abuse
E Diffuse scleroderma
answere is D) analgesic abuse causing ANALGESIC NEPHROPATHY

Since patient had increasing malaise for a an year most likely used analgesics.Analgesics(aspirin,acetominophen)releas e free radicals which damage renal medulla and inhibits PGE 2 which leaves Angiotensin II unopposed leading to hypertension by vasoconstriction also decreases blood flow to renal medulla leading to renal papillary necrosis(hyperplastic arteiosclerosis with fibrinoid necrosis,bilaterally small with granular surface)
analgesics abuse can also cause petechial hemorrhages

Last edited by docusmle9; 08-04-2011 at 12:16 AM.
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  #7  
Old 08-04-2011
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it is anelgesic abuse
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  #8  
Old 08-04-2011
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According to Goljan analgesic nephropathy: acetaminophen + aspirin for 3 or more years.

The blood pressure above 210/120 mmHg looks like malignant hypertension.
i'm thinking B
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Old 08-04-2011
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[QUOTE=dr_lizard;58331]A 45-year-old woman has had increasing malaise for the past year. On physical examination her blood pressure is 265/150 mm Hg. Laboratory studies show a plasma renin activity of 9 ng/mL/hr. She then suffers a "stroke" with a right basal ganglia hemorrhage and dies. At autopsy the kidneys are bilaterally small with granular surfaces. Microscopically they show hyperplastic arteriolosclerosis with fibrinoid necrosis, petechial hemorrhages, and microinfarcts in the cortices. Which of the following conditions is most likely to be her underlying cause of death?

A Diabetes mellitus, type II
B Fibromuscular dysplasia
C Factor V Leiden mutation
D Analgesic abuse
E Diffuse scleroderma[/Q

answer is B.....fibromuscular dysplasia...malignanat hypertension having FLEA BITTEN KIDNEY...
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  #10  
Old 08-04-2011
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Why not C.?
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  #11  
Old 08-04-2011
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yea i was thinking fibromuscular dysplasia because of hypertension
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Old 08-04-2011
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B). Fibromuscular dysplasia-which mostly affects the renal arteries...

i also thought A).DM causing renal artery atheroscerosis, which activates RAAS, leading to malignant HTN and the mentioned changes thereafter... i kno it usually occurs in the elderly(>60years).....Can some1 explain ne stronger reason?...thanx in advance
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  #13  
Old 08-04-2011
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Quote:
Originally Posted by usmle2011 View Post
But for sclerodema there are no pointers like Raynauds phenomenon, sclerodactyly, esophageal dysmotility

I think its Fibromuscular dysplasia
@usmle2011, Diffuse scleroderma is not the same as CREST!!!

Bilateral fibromuscular dysplasia???...the kidneys are bilaterally small with granular surfaces...

Severe complications from scleroderma in the kidney:
- Scleroderma renal crisis in which malignant hypertension develops and causes acute renal failure was once a common cause of death, but is now treatable with ACE inhibitors.
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  #14  
Old 08-04-2011
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i think it is E- fibromuscular dysplasia
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Old 08-04-2011
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Quote:
Originally Posted by bebix View Post
@usmle2011, Diffuse scleroderma is not the same as CREST!!!

Bilateral fibromuscular dysplasia???...the kidneys are bilaterally small with granular surfaces...

Severe complications from scleroderma in the kidney:
- Scleroderma renal crisis in which malignant hypertension develops and causes acute renal failure was once a common cause of death, but is now treatable with ACE inhibitors.
hey bebix!!!..me not able to understand ur answer...bilateral fibromuscular dysplasia is not possible???..in fibromuscular dysplasia induced malignant hypertension there is FLEA BITTEN KIDNEY as long as i knw...u have written that kidneys are bilateraly small and granular surface thats why answer is SCLERODERMA RENAL CRISIS..can u explain in detail please!!!...THANKS IN ADVANCE..
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  #16  
Old 08-04-2011
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Quote:
Originally Posted by dr.digant View Post
hey bebix!!!..me not able to understand ur answer...bilateral fibromuscular dysplasia is not possible???..in fibromuscular dysplasia induced malignant hypertension there is FLEA BITTEN KIDNEY as long as i knw...u have written that kidneys are bilateraly small and granular surface thats why answer is SCLERODERMA RENAL CRISIS..can u explain in detail please!!!...THANKS IN ADVANCE..
@dr.digant
Flea bitten kidney is due to malignant hypertension (and also the hyperplastic arteriolosclerosis)...does not matter much the cause of it...ALL malignant hypertension has the same postmortem finding...
Now, most of the fibromuscular dysplasia are unilateral...but here the postmortem finding are bilateral*.

*bilaterally small vs asymmetric

Last edited by bebix; 08-04-2011 at 07:29 AM.
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  #17  
Old 08-04-2011
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Quote:
Originally Posted by bebix View Post
@dr.digant
Flea bitten kidney is due to malignant hypertension (and also the hyperplastic arteriolosclerosis)...does not matter much the cause of it...ALL malignant hypertension has the same postmortem finding...
Now, most of the fibromuscular dysplasia are unilateral...but here the postmortem finding are bilateral*.

*bilaterally small vs asymmetric
thanks bebix.....have given any nbme????
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  #18  
Old 08-04-2011
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Answer Analgesic Nephropathy.
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  #19  
Old 08-04-2011
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Quote:
Originally Posted by bebix View Post
@usmle2011, Diffuse scleroderma is not the same as CREST!!!

Bilateral fibromuscular dysplasia???...the kidneys are bilaterally small with granular surfaces...

Severe complications from scleroderma in the kidney:
- Scleroderma renal crisis in which malignant hypertension develops and causes acute renal failure was once a common cause of death, but is now treatable with ACE inhibitors.
Ohk So FMD has unilateral involvement cudnt find it in Goljan.
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  #20  
Old 08-04-2011
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Quote:
Originally Posted by usmle2011 View Post
Ohk So FMD has unilateral involvement cudnt find it in Goljan.
how about here:

Fibromuscular Dysplasia
David P. Slovut, M.D., Ph.D., and Jeffrey W. Olin, D.O.
New England Journal of Medicine 2004; 350:1862-1871 April 29, 2004

1/3 cases are bilateral.

Female with Renal Hypertension-nejm.jpg
click image to enlarge
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  #21  
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Quote:
Originally Posted by bebix View Post
how about here:

Fibromuscular Dysplasia
David P. Slovut, M.D., Ph.D., and Jeffrey W. Olin, D.O.
New England Journal of Medicine 2004; 350:1862-1871 April 29, 2004

1/3 cases are bilateral.

Attachment 1856

Thanx a lot dear

U rock !!!!!!!!!
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  #22  
Old 08-04-2011
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Thumbs Up the answer is E)

A) Incorrect. Diabetes mellitus can produce a variety of renal diseases, among them hyaline arteriolosclerosis.

B) Incorrect. Fibromuscular dysplasia typically affects the main renal arteries.

C) Incorrect. Factor V Leiden mutation is one of the most common forms of inherited coagulopathy. Patients typically have a history of thrombosis starting at a young age. Hypertension is not a typical feature.

D) Incorrect. Analgesic abuse can lead to papillary necrosis, interstitial fibrosis, and microangiopathy with basement membrane thickening.

E) CORRECT. She has findings of severe, malignant hypertension. This is likely to complicate diffuse scleroderma, but not the more limited form of scleroderma--CREST syndrome.

I also thought the answer was B) ...

Here is the source
http://library.med.utah.edu/WebPath/...G/ren1frm.html
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  #23  
Old 08-04-2011
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Correct Answer correct answer is E

prepink thanks for that!
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  #24  
Old 08-05-2011
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Thanks a lot for the question, turned out to be trickier than i thought

Thank you too prepink, it's a great link.
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