A 65-Year-Old Man With Hypertension and Proteinuria

Pradeep Arora, MD; Karen Convay, NP

Disclosures

October 12, 2015

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case you would like to suggest for a future Case Challenge, please contact us.

Background

A 65-year-old black male with a history of hypertension for more than 30 years was referred to the nephrologist for evaluation of proteinuria. Recently, his hypertension became uncontrolled despite the use of four antihypertensive medications. These included lisinopril (60 mg daily), nifedipine (60 mg daily), atenolol (100 mg daily), and hydrochlorothiazide (50 mg once a day).

The patient was diagnosed with type 2 diabetes mellitus when admitted in a hyperosmolar state nearly 20 years ago. Control of his diabetes was suboptimal at that time, with an average A1c level of 9%. He was also diagnosed with infective endocarditis, which was treated with ceftriaxone and methicillin. Within the next year, he was diagnosed with diabetic neuropathy, diabetic retinopathy after laser therapy, gastroparesis, and erectile dysfunction.

The patient's serum creatinine level before admission for infective endocarditis was 0.9 mg/dL; he subsequently developed acute kidney injury (AKI). Around 6 years ago, his estimated glomerular filtration rate (eGFR) was 50 mL/min/1.73 m2 with 6 g for proteinuria when referred to nephrology. He has been diagnosed with biopsy-proven chronic active hepatitis, which was not considered to be treatable.

Figure 1.

He was prescribed lisinopril, advised to restrict salt, and switched to furosemide from hydrochlorothiazide. Despite several educational sessions, the patient's hypertension and blood sugar level remained at the upper level of poor control. His eGFR decreased to 20 mL/min 3 years prior to the current presentation. Last year, he presented to the emergency department with shortness of breath; his leg showed livedo reticularis and violaceous, painful, plaquelike subcutaneous nodules, which progressed to ischemic and necrotic ulcers with eschars (Figure 1).

The patient denies a history of coronary artery disease or stroke. His appetite has been fair, without dietary restriction. He denies fever, vomiting, decreased urine output, joint pain, or rash. He reports fatigue and increased nocturnal urinary frequency.

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