Malignant hypertension may on occasion be associated with microangiopathic hemolytic anemia. A 45-year-old male presented with stiff neck, nausea, poor appetite, and dyspnea on exertion for 1-2 weeks before admission. He was diagnosed with hypertensive emergency with cardiac and renal dysfunction. The presence of thrombotic microangiopathy (TMA) was determined based on the presence of schistocytes on peripheral smear and laboratory data, including hemoglobin 9 g/dL, total bilirubin 0.5 mg/dL, haptoglobin 72 mg/dL (30-200), platelet count 59 000/μL, and reticular cell count 7.1% (2-0.5%). The cause of TMA was unclear. This patient denied having diarrhea, making hemolytic uremic syndrome unlikely. Normal ADAMTS13 activity also ruled out thrombotic thrombocytopenic purpura. Malignant hypertension-induced TMA was impressed. Plasmapheresis with plasma replacement was arranged. Renal biopsy revealed features of TMA and malignant nephrosclerosis. This patient has been dialysis-dependent for more than 3 months and his hypertension has been treated aggressively with multiple medications.
