Renovascular Hypertension with Progressive Atherosclerotic Renal Artery Stenosis in an Elderly Patient with Known Fibromuscular Dysplasia: A Case Report.

BACKGROUND Atherosclerotic renal artery stenosis (ARAS) and renovascular fibromuscular dysplasia (FMD) are 2 of the most common etiologies of renovascular hypertension. They have different pathophysiologies, risk factors, presentations, and treatment options. However, as our population ages, it can become increasingly common to see patients who previously had FMD who develop ARAS at an advanced age, indicated by recurrent renovascular hypertension. CASE REPORT We present a case of a 66-year-old female patient who, in 2007, had presented with uncontrolled hypertension. She underwent magnetic resonance angiography and was found to have bilateral FMD, for which she received balloon angioplasty to a severe lesion on the mid-right renal artery and subsequently had normalization of blood pressures and resolution of symptoms. In 2021 she returned with uncontrolled hypertension while being treated with 3 antihypertensives. Bilateral renal arteriography revealed new severe ostial stenosis of the left renal artery and a patent right renal artery in which balloon angioplasty was performed 14 years ago. Based on the angiographic pattern of this new left RAS, we concluded this lesion was caused by atherosclerosis. The left ostial lesion was treated with a bare-metal stent and the patient was continued on antihypertensive medication and statin; at follow-up 4 months later, her blood pressures had normalized. CONCLUSIONS This case features a patient who developed severe ARAS with underlying history of bilateral renal artery FMD. Clinicians need to be aware that in patients with FMD, worsening renovascular hypertension at an advanced age could indicate the development of new hemodynamically significant ARAS. These patients need repeat diagnostic testing and treatment with medial optimization with or without endovascular revascularization in the appropriate clinical setting.

Extraordinary Creatine Phosphokinase Levels in Coxsackie B Necrotizing Myopathy Complicated by Rhabdomyolysis.

Coxsackie B infections can have varying clinical presentations. Necrotizing myopathy and rhabdomyolysis with remarkably high creatine phosphokinase levels is a rare complication associated with high morbidity and mortality. A 28-year-old male presented with complaints of weakness, body aches, and decreased urine output. Initial lab work showed a creatine phosphokinase level estimated at 5,366,100 U/l. Initial Coxsackie B4 titers were at 1:160. Muscle biopsy of the right calf revealed necrotizing myopathy consistent with viral myopathy. This case highlights Coxsackie B4 as a potential pathogen that can cause extensive muscle necrosis producing extreme creatine phosphokinase levels leading to rhabdomyolysis. Taking a comprehensive history is essential to identify viral prodromal symptoms to guide broader serological testing for uncommon viral species.