A 52-year-old woman presents to the ER with BP 220/130 mmHg, severe headache, and fundoscopy showing flame haemorrhages, cotton wool spots, and papilloedema. Urinalysis shows 2+ proteinuria and red cell casts. Creatinine has risen from 0.9 to 2.1 mg/dL in the last 24 hours. This is best characterised as:

• A Hypertensive urgency
• B Hypertensive emergency with hypertensive nephrosclerosis
• C Malignant hypertension with thrombotic microangiopathy ✓
• D IgA nephropathy with accelerated hypertension

Explanation

Malignant hypertension is defined by severely elevated BP with papilloedema AND evidence of target-organ damage. Red cell casts and acute kidney injury here reflect thrombotic microangiopathy (TMA) — fibrinoid necrosis of small renal vessels causing glomerular ischaemia. This is distinct from hypertensive urgency (no target-organ damage) and hypertensive nephrosclerosis (chronic, gradual). Management requires immediate controlled BP reduction (IV labetalol or nicardipine, targeting 20–25% MAP reduction in 1–2 hours) with ICU monitoring. Overly rapid reduction risks end-organ ischaemia.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.