Practice Lesson of the Week

Giant cell arteritis causing aortic dissection and acute hypertension

BMJ 2008; 337 doi: (Published 04 July 2008) Cite this as: BMJ 2008;337:a426
  1. Yvo M Smulders, consultant internist1,
  2. Dominique W M Verhagen, consultant internist1
  1. 1VU University Medical Center, Division of Internal Medicine, PO Box 7057, Amsterdam 1081HV, Netherlands
  1. Correspondence to: Y M Smulders y.smulders{at}
  • Accepted 2 October 2007

Recent onset hypertension should prompt investigation for secondary causes

Recent onset hypertension should prompt investigation for secondary causes. This search routinely includes screening for mineralocorticoid excess, renal artery stenosis, and, in selected cases, phaeochromocytoma. We present the case of an elderly woman with recent onset hypertension, hypokalaemia, and a raised erythrocyte sedimentation rate. The cause of the hypertension was presumed to be aortic dissection with compromised renal blood flow, but the erythrocyte sedimentation rate provided the clue to the final diagnosis.

Case report

A 74 year old woman was referred because of general malaise and hypertension. During the previous months she had reported fatigue, lack of appetite and weight loss, and muscle weakness. About three weeks before admission she had had sudden onset abdominal pain and diarrhoea, for which no medical aid was sought and which subsided spontaneously after a few days. Her medical history was unremarkable. In particular, her blood pressure had been only mildly raised (160/90 mm Hg, measured repeatedly during previous years, most recently two months before admission).

On examination she had severe hypertension (215/125 mm Hg) but no other abnormalities. Results of vascular, funduscopic, and abdominal examination were normal. Routine laboratory tests showed a raised erythrocyte sedimentation rate (85 mm/h), low plasma sodium (131 mmol/l) and potassium (2.8 mmol/l), moderately raised serum creatinine (111 μmol/l), and mild chronic metabolic alkalosis (arterial pH 7.51, bicarbonate 32 mmol/l). Urinary potassium concentration was 51 mmol/l, and there …

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