A 40-year-old man presents with headache and blood pressure of 230/140 mmHg. Fundoscopy shows flame hemorrhages and papilledema. Renal biopsy demonstrates concentric lamination of arteriolar wall cells producing an onion skin appearance with narrowed lumen. The arteriolar change described is:
- A Hyperplastic arteriolosclerosis ✓
- B Hyaline arteriolosclerosis
- C Monckeberg medial calcific sclerosis
- D Fibrinoid necrosis of the arteriole
Correct answer: A. Hyperplastic arteriolosclerosis
Explanation
Malignant hypertension causes hyperplastic arteriolosclerosis, defined by laminated concentric smooth muscle hyperplasia and basement membrane duplication producing the onion skin lesion, often with superimposed fibrinoid necrosis and necrotizing glomerulitis when pressure is extreme. Hyaline arteriolosclerosis is the bland, glassy thickening of benign hypertension and diabetes, which makes it the tempting but incorrect distractor for this acute severe presentation.
Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.
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