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Adenoma of the adrenal cortex
19%
28/151
Atherosclerotic plaques in the renal artery
16%
24/151
Cystic change in the kidney parenchyma bilaterally
5%
7/151
Intermittent reductions in renal artery diameter
41%
62/151
Tumor of the adrenal medulla
7%
10/151
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This young woman who presents with hypertension worsened by lisinopril as well as hypernatremia and hypokalemia most likely has fibromuscular dysplasia, which would present with intermittent reductions in renal artery diameter. Fibromuscular dysplasia is a cause of secondary hypertension due to narrowing of the renal arteries. It typically occurs in young women and can be seen on magnetic resonance angiography as a "string-of-beads" appearance due to intermittent reductions in the diameter of the renal artery. Patients with this disease will present with severe hypertension that is refractory to antihypertensive agents and may be worsened by angiotensin converting enzyme inhibitors. Furthermore, poor perfusion of the kidneys will lead to increased release of renin and subsequent production of aldosterone. Aldosterone will mediate sodium reabsorption and potassium wasting such that over time the patient will develop hypernatremia and hypokalemia. Incorrect Answers: Answer 1: Adenoma of the adrenal cortex may also lead to secondary hypertension because of hyperaldosteronism; however, patients with Conn syndrome will not have worsening of hypertension after administration of lisinopril because they do not have a problem with kidney perfusion. Answer 2: Atherosclerotic plaques in the renal artery would be seen in patients with renal artery stenosis due to atherosclerosis. In general, these patients tend to be men over the age of 50 rather than young women. Answer 3: Cystic change in the kidney parenchyma bilaterally would be seen in patients with autosomal dominant polycystic kidney disease. This disease may present with progressive kidney failure and uremia but is unlikely to present with isolated hypertension. Answer 5: Tumor of the adrenal medulla would be seen in patients with pheochromocytoma and can present with extremely high blood pressures due to adrenergic vasoconstriction; however, these patients would not have hypernatremia and hypokalemia. Bullet Summary: Fibromuscular dysplasia causes secondary hypertension in young women and can be seen as a "string-of-beads" on angiography.
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