What came first, atypical hemolytic uremic syndrome or malignant hypertension: a clinical dilemma

Figures & data

Table 1. Laboratory investigations.

Investigations	Results Units (reference range)
Complete Blood Count
Haemoglobin	6.5 mg/dl (11.5–15.5)
WBC	8.72 (5–13 *10^3/uL)
Reticulocytes	7.3 % (0.5–1.5)%
Neutrophil	73.2%
Lymphocyte	18.2%
Eosinophil	0.9%
Monocytes	7.5%
Basophils	0.2%
Platelet Count	100 (170–450 * 10^^3/uL)
Lactate Dehydrogenase	2677 U/L (120–246)U/L
Serum Haptoglobin	<10 mg/dl (>50mg/dl)
Peripheral smear	Anisopoikilocytosis; fragmented cells, 4.9% schistocytes
Direct Coombs Test	Negative
Bilirubin Total	2.1 mg/dl (0.1–1)
Indirect Bilirubin	1.6 mg/dl (0.1–0.8)
Urea	68 mg/dl (20–40)
Creatinine	3.2 mg/dl (0.7–1.0)
Urine
Urine examination	3+ protein; absent RBCs, WBCs and casts
Urine protein creatinine ratio	4.10
Immunology
ANCA	Negative
ANA	Negative
C3 (mg/dL)	84 (70–110)
C4 (mg/dl)	20 (10–40)
ADAMTS 13 activity	65% (60–130%)
Anti-factor H antibodies	Negative
Radiology
Echocardiography	Concentric left ventricular hypertrophy
Ultrasound abdomen	Both kidneys normal sized, echogenic with loss of corticomedullary differentiation.

Normal values are mentioned within brackets.

Figure 1. DMSA nuclear scan showing mildly lobulated contour with cortical scarring in upper poles of both kidneys.

Figure 2. Micturating cystourethrogram image showing right grade-III vesicoureteric reflux. Mild bladder wall irregularities are present. No reflux is seen on left side.

Figure 3. Cascade of events in hypertensive crisis that can lead to thrombotic microangiopathy. RAAS: renin-angiotensin-aldosterone system; NO: nitric oxide; TXA2: Thromboxane A2.