Hypertensive emergency presenting with diffuse alveolar hemorrhaging and thrombotic microangiopathy: A case report and review of the literature.

There are few studies reporting diffuse alveolar hemorrhage (DAH) caused by hypertensive emergency. We describe a 41-year-old man who visited the emergency room with hemoptysis and dyspnea. He had a 5-year history of hypertension, though he had not received any treatment. His blood pressure was 233/159 mmHg, his percutaneous oxygen saturation level was 88% on room air, and he had a serum creatinine level of 11.7 mg/dL. Laboratory data showed microangiopathic hemolytic anemia, thrombocytopenia, and severe kidney damage, suggesting thrombotic microangiopathy (TMA). Chest computed tomography and bronchoalveolar lavage revealed pulmonary alveolar hemorrhage. In addition to steroid treatment and plasma exchange, antihypertensive therapy was started immediately. On day 3, activity of a disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13 (ADAMTS13) activity was not significantly reduced, and clinical markers for vasculitis and connective tissue disease were negative. Therefore, steroid administration and plasma exchange were discontinued. Although antihypertensive therapy centering on angiotensin II receptor blocker was effective for DAH and TMA, renal function did not recover, and maintenance hemodialysis was required. Renal pathological findings were consistent with malignant nephrosclerosis, and features suggestive of vasculitis were not found. The pathophysiology in this case was considered to be mainly hypertension and vascular endothelial injury with renin-angiotensin-aldosterone system (RAAS) activation. The use of RAAS inhibitor was effective in converging DAH and TMA, and it was expected to repair vascular endothelial damage associated with appropriate antihypertensive intervention. The authors present this rare condition with a review of previous reports.

Clostridioides difficile-related toxic megacolon after Cryptococcus neoformans cellulitis: A complex of two rare infections in an immunocompromised host.

A 76-year-old Japanese woman was admitted due to uncontrolled cellulitis of the right lower leg. She had deep vein thrombosis on the right limb. Moreover, she had a long history of rheumatoid arthritis treated with corticosteroids. Skin biopsy and lumbar puncture were performed to diagnose disseminated cryptococcosis. She was administered antifungal agents (liposomal amphotericin B and 5-fluorocytosine). On treatment day 14, debridement was performed, and cryptococcosis was controlled. However, she developed toxic megacolon due to Clostridioides difficile infection (CDI). On day 32, she was transferred to the intensive care unit due to severe acidosis and acute kidney injury secondary to CDI-related toxic megacolon. Vancomycin, metronidazole, and tigecycline were administered for treatment of CDI. After several weeks of intensive care, toxic megacolon was improved, but renal replacement therapy was discontinued according to the patient's will. On day 73, she died of renal failure. We experienced a complex of rare diseases, Cryptococcus neoformans cellulitis and Clostridioides difficile-related toxic megacolon. Both diseases were presumed to be the result of corticosteroid and methotrexate use. Hence, careful monitoring is required when treating immunocompromised hosts to reduce the risk of developing complications.