A 22-year-old man presents with frequent headaches. He plays baseball on weekends but over the last 3 months has noticed a dry cough and decreased exercise tolerance due to shortness of breath. The patient has also had lower extremity swelling and says that his face feels "puffy." He is a lifetime nonsmoker and does not use alcohol or illicit drugs. Blood pressure is 180/102 mm Hg in the right arm and 183/99 mm Hg in the left and pulse is 85/min and regular. BMI is 24 kg/m2. Upper and lower extremity pulses are equal. Bilateral lower extremity edema is present. The remainder of the physical examination is normal. ECG shows normal sinus rhythm. Urinalysis shows 2+ protein. Which of the following is the most likely cause of this patient's condition?
一名 22 岁的男性出现频繁头痛。他在周末打棒球，但在过去的 3 个月里注意到干咳和由于呼吸急促导致的运动耐力下降。患者还出现下肢肿胀，并表示他的脸感觉“肿胀”。他是终身不吸烟者，不饮酒或使用非法药物。右臂血压为 180/102 mm Hg，左臂为 183/99 mm Hg，脉搏为 85 次/分钟且规律。BMI 为 24 kg/m²。上下肢脉搏相等。双侧下肢水肿明显。其余体格检查正常。心电图显示正常窦律。尿液分析显示 2+蛋白。以下哪项是该患者病情最可能的原因？
A. | Adrenal cortical tumor 肾上腺皮质肿瘤 | |
B. | Adrenal medullary tumor 肾上腺髓质肿瘤 | |
C. | Congenital narrowing of the aorta 先天性主动脉狭窄 | |
D. | Renal artery stenosis 肾动脉狭窄 | |
E. | Renal parenchymal disease 肾实质疾病 |
Common causes of secondary hypertension by age 按年龄 | |
≤20 |
|
21-39 |
|
40-64 |
|
≥65 |
|
The following clinical features suggest a secondary cause of hypertension:
以下临床特征提示<强 id=0>高血压的继发性原因：
- Onset at age <30
在年龄 <30时发作 - Acute blood pressure increase in a patient with previously stable values
先前稳定值患者的急性血压升高 - Evidence of end-organ damage (eg, retinal hemorrhages, heart failure)
终末器官损伤的证据（例如，视网膜出血，心力衰竭） - Severe or resistant hypertension (ie, uncontrolled despite an appropriate 3-drug regimen)
严重或耐药性高血压（即，在适当的三药方案下仍无法控制）
Renal parenchymal disease (eg, glomerulonephritis, vesicoureteral reflux) is a common cause of secondary hypertension in young adults and is the likely cause in this patient. Glomerulonephritis may develop subacutely and may be associated with variable degrees of proteinuria.
肾实质疾病（例如，肾小球肾炎，膀胱输尿管反流）是年轻人中继发性高血压的常见原因，并且可能是该患者的原因。肾小球肾炎可能亚急性发展，并可能伴有不同程度的蛋白尿。
Hypertension is more common in glomerular disease with a nephritic presentation (ie, hematuria with less prominent proteinuria) but can also occur with a nephrotic presentation characterized by proteinuria >3.5 g/day and edema (eg, facial puffiness, lower extremity swelling). In both cases, hypertension is likely caused by increased renal sodium absorption due to resistance to atrial natriuretic peptide and elevated activity of collecting tubule sodium-potassium pumps.
高血压在肾小球疾病中更常见，尤其是肾炎表现（即血尿伴随不明显的蛋白尿），但也可以出现在肾病综合征表现中，特征为蛋白尿超过 3.5 克/天和水肿（例如，面部浮肿、下肢肿胀）。在这两种情况下，高血压可能是由于对心房利钠肽的抵抗和集合小管钠钾泵活性升高导致的肾脏钠吸收增加。
(Choice A) Adrenal cortical tumors can cause secondary hypertension as a manifestation of Cushing syndrome or hyperaldosteronism. However, Cushing syndrome usually causes characteristic physical features, and hyperaldosteronism rarely causes edema due to aldosterone escape. Both conditions are uncommon in young adults.
(选择 A) 肾上腺皮质肿瘤可以导致继发性高血压，作为库欣综合症或醛固酮增多症的表现。然而，库欣综合症通常会导致特征性身体特征，而醛固酮增多症很少因醛固酮逃逸而导致水肿。这两种情况在年轻成年人中都不常见。
(Choice B) Adrenal medullary pheochromocytoma secretes catecholamines and usually presents with hypertension associated with episodic headaches, flushing, sweating, and tachycardia, which are absent in this patient. In addition, edema and decreased exercise tolerance would not be expected.
(选择 B) 肾上腺髓质嗜铬细胞瘤分泌儿茶酚胺，通常表现为与发作性头痛、潮红、出汗和心动过速相关的高血压，而该患者没有这些症状。此外，不会预期出现水肿和运动耐受性下降。
(Choice C) Coarctation of the aorta typically presents in childhood, not young adulthood, with upper extremity hypertension that may be accompanied by headache, epistaxis, and symptoms of lower extremity claudication. Equal upper and lower extremity pulses make coarctation unlikely, and edema would not be expected.
(Choice C) 主动脉狭窄通常在儿童期表现出来，而不是在年轻成人期，伴有上肢高血压，可能伴有头痛、鼻出血和下肢间歇性跛行的症状。 上下肢脉搏相等使得狭窄不太可能，并且不应出现水肿。
(Choice D) Renal artery stenosis due to atherosclerosis is most often seen in patients age >65 and would be very unusual in a young man. Fibromuscular dysplasia is a potential cause of renal artery stenosis in young patients but overwhelmingly affects female patients (~90% of cases).
(选择 D) 由于动脉粥样硬化引起的肾动脉狭窄最常见于 65 岁以上的患者，在年轻男性中则非常不寻常。纤维肌肉发育不良是年轻患者肾动脉狭窄的潜在原因，但主要影响女性患者（约占 90%的病例）。
Educational objective: 教育目标：
Renal parenchymal disease is an important cause of secondary hypertension in adults age <30. Glomerulonephritis, with either a nephritic or nephrotic presentation, can lead to secondary hypertension due to increased renal sodium reabsorption.
肾实质疾病是 30 岁以下成年人继发性高血压的重要原因。肾小球肾炎，无论是肾炎型还是肾病型表现，都可能由于肾脏钠重吸收增加而导致继发性高血压。
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