What is the most likely diagnosis and immediate management for a 35‑year‑old woman with severe hypertension, a 4‑day history of continuous crushing headache radiating to the nape, projectile vomiting, brief earthquake‑like dizziness, no focal neurological deficits, systemic lupus erythematosus on prednisone, chronic kidney disease, type‑2 diabetes, and acute otitis media?

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Diagnosis: Hypertensive Emergency with Possible Malignant Hypertension and Acute Otitis Media

This 35-year-old woman with severe hypertension (177/130 mmHg), crushing headache with projectile vomiting, brief dizziness, and multiple comorbidities (SLE, CKD, diabetes) requires immediate ICU admission for hypertensive emergency management, urgent brain imaging to exclude intracranial pathology, and comprehensive evaluation for acute target-organ damage. 1

Immediate Classification: Emergency vs. Urgency

This presentation meets criteria for hypertensive emergency based on:

  • Blood pressure >180/120 mmHg (177/130 mmHg on initial reading, 160/100 mmHg on recheck) 1
  • Neurologic symptoms highly suggestive of acute target-organ damage:
    • Continuous crushing headache radiating to the nape with projectile vomiting indicates possible hypertensive encephalopathy 1, 2
    • "Earthquake sensation" dizziness represents impaired cerebral autoregulation in severe hypertension 2
    • The combination of headache, vomiting, and unsteadiness significantly increases the likelihood of intracranial pathology requiring immediate identification 2, 3

The presence of neurologic symptoms—not the absolute BP value—is what distinguishes hypertensive emergency from urgency. 1 Even though the recheck BP was 160/100 mmHg, the initial severe elevation with concerning neurologic symptoms mandates emergency classification. 1

Critical Immediate Actions (Within Minutes)

1. ICU Admission with Continuous Monitoring

  • Immediate ICU admission with continuous arterial-line blood pressure monitoring (Class I recommendation) 1
  • This is non-negotiable given the neurologic symptoms and severe hypertension 1

2. Urgent Brain Imaging

  • MRI brain is the preferred imaging modality for this patient with hypertensive urgency and unsteadiness, as neurological symptoms significantly increase the likelihood of intracranial pathology 2
  • MRI with FLAIR imaging is superior for detecting posterior reversible encephalopathy syndrome (PRES), which shows white matter lesions in posterior brain regions that are fully reversible with timely treatment 1
  • Do not delay imaging while attempting blood pressure reduction—identifying the underlying pathology guides appropriate BP targets and treatment intensity 2
  • If MRI is unavailable or contraindicated, obtain CT head immediately to exclude hemorrhage or mass effect 1

Critical pitfall: Do not dismiss unsteadiness as "benign" dizziness in hypertensive urgency—this symptom pattern specifically increases the likelihood of intracranial abnormalities, and the absence of focal deficits on exam does not exclude hypertensive encephalopathy, PRES, or early stroke. 2

3. Comprehensive Laboratory Evaluation

Mandatory immediate laboratory panel: 1, 2

  • Complete blood count (hemoglobin, platelets) to assess for microangiopathic hemolytic anemia
  • Basic metabolic panel (creatinine, sodium, potassium) to evaluate renal function—critical given her CKD
  • Lactate dehydrogenase (LDH) and haptoglobin to detect hemolysis in hypertensive thrombotic microangiopathy
  • Urinalysis for protein and urine sediment (erythrocytes, leukocytes, cylinders) to identify renal damage
  • Troponin (given her diabetes and cardiovascular risk)
  • ECG to assess for cardiac involvement

4. Fundoscopic Examination

  • Dilated fundoscopy is essential to look for bilateral retinal hemorrhages, cotton-wool spots, or papilledema (grade III-IV retinopathy) 1, 2
  • The presence of these findings would confirm malignant hypertension and necessitate more aggressive management 1
  • This examination must be performed immediately—it is the only way to definitively diagnose malignant hypertension 2

Blood Pressure Management Strategy

Initial Target (First Hour)

Reduce mean arterial pressure by 20-25% within the first hour using IV antihypertensive therapy 1

  • Current MAP = (177 + 2×130)/3 = 146 mmHg
  • Target MAP after 1 hour = 110-117 mmHg (approximately 140-150/90-95 mmHg)

Critical safety consideration: Avoid systolic drops >70 mmHg to prevent cerebral, renal, or coronary ischemia, especially critical in this patient with CKD and chronic hypertension who has altered autoregulation 1

Subsequent Targets

  • Hours 2-6: Lower to ≤160/100 mmHg if patient remains stable 1
  • Hours 24-48: Gradually normalize blood pressure 1

If MRI confirms hypertensive encephalopathy or PRES: Immediate MAP reduction by 20-25% is required, and lesions are typically reversible with timely recognition and appropriate BP management 1, 2

First-Line IV Antihypertensive Therapy

Preferred Agent: Nicardipine

Nicardipine is the first-line agent for this patient because: 1

  • Preserves cerebral blood flow without raising intracranial pressure—critical for suspected hypertensive encephalopathy
  • Allows predictable, titratable control
  • Rapid onset (5-15 min) and short duration (30-40 min)
  • Particularly effective for hypertensive emergencies with neurologic involvement

Dosing protocol: 1

  • Start 5 mg/h IV infusion
  • Increase by 2.5 mg/h every 15 minutes until target BP reached
  • Maximum 15 mg/h

Alternative Agent: Labetalol

Labetalol is an acceptable alternative and may be preferred given her renal involvement (CKD): 1

  • Excellent choice for hypertensive emergencies with renal involvement
  • Dual alpha and beta-blocking action

Dosing protocol: 1

  • 10-20 mg IV bolus over 1-2 minutes
  • Repeat or double every 10 minutes (max cumulative 300 mg)
  • OR continuous infusion 2-8 mg/min

Contraindications to check: Reactive airway disease, COPD, heart block, bradycardia, decompensated heart failure 1

Special Considerations for This Patient

Systemic Lupus Erythematosus

  • SLE patients have increased risk of malignant hypertension 4
  • Hypertension in SLE is closely related to early mortality and is reported in 14-58% of patients 4
  • Malignant hypertension can occur in SLE patients even without clinical evidence of antiphospholipid syndrome or hypertensive nephropathy 4
  • After stabilization, screen for secondary causes: 20-40% of malignant hypertension cases have identifiable etiologies including renal artery stenosis, pheochromocytoma, primary aldosteronism 1

Chronic Kidney Disease

  • Use labetalol as first-line for malignant hypertension with renal failure, targeting 20-25% MAP reduction over several hours 1
  • Volume depletion from pressure natriuresis may occur—intravenous saline may be needed to correct precipitous BP falls 1
  • Monitor creatinine closely—a modest rise up to ≈30% is expected and acceptable during acute management 1

Diabetes Management

  • Stressful events (including hypertensive crisis) frequently aggravate glycemic control and may precipitate diabetic ketoacidosis or hyperosmolar state 1
  • Any condition with marked hyperglycemia accompanied by vomiting or altered consciousness requires temporary adjustment of treatment and immediate interaction with diabetes care team 1
  • Patient may temporarily require insulin even if previously managed with oral agents alone 1

Prednisone Use

  • Steroids are a contributing factor to hypertensive emergencies 1
  • Continue prednisone for SLE control but recognize it may be contributing to BP elevation

Management of Acute Otitis Media

The pus-like material on otoscopy represents acute otitis media requiring treatment, but this is NOT the cause of her hypertensive emergency. 1

  • Initiate appropriate antibiotic therapy (e.g., amoxicillin-clavulanate)
  • Pain from otitis media could theoretically contribute to transient BP elevation, but the severity and duration of her symptoms indicate true hypertensive emergency 1

Critical pitfall: Do not attribute the entire clinical picture to pain from otitis media—many patients with acute pain have transiently elevated BP that normalizes when the underlying condition is treated, but this patient's 4-day history of severe symptoms with neurologic findings indicates true target-organ damage. 1

Post-Stabilization Management (24-48 Hours)

Transition to Oral Therapy

  • After stabilization, transition to oral antihypertensive regimen combining: 1
    • Renin-angiotensin system blocker (continue or optimize current telmisartan)
    • Calcium channel blocker (add if not already on one)
    • Diuretic (thiazide or thiazide-like for chronic BP control; loop diuretic if volume overload)

Target Blood Pressure

  • Long-term target: <130/80 mmHg for most patients 1
  • Given her SLE, CKD, and diabetes, this stringent target is appropriate 5

Medication Reconciliation

  • Address medication non-adherence—the most common trigger for hypertensive emergencies 1
  • Patient reports "lost prior prescription" and "other unrecalled medications"—this suggests possible non-adherence
  • Provide clear written instructions and consider fixed-dose combination pills to improve adherence 1

Follow-Up Schedule

  • Monthly follow-up visits until target BP <130/80 mmHg is achieved and organ-damage findings regress 1
  • Patients with prior hypertensive emergency remain at markedly increased cardiovascular and renal risk 1

Prognosis

Without treatment, hypertensive emergencies carry >79% one-year mortality and median survival of only 10.4 months. 1 However, with proper acute management and long-term control, survival has improved significantly over recent decades. 1

Summary Algorithm

  1. Immediate ICU admission with arterial-line monitoring 1
  2. Urgent MRI brain (or CT if MRI unavailable) 2
  3. Comprehensive labs (CBC, BMP, LDH, haptoglobin, UA, troponin, ECG) 1
  4. Fundoscopy to assess for malignant hypertension 1, 2
  5. Start IV nicardipine 5 mg/h, titrate to reduce MAP by 20-25% in first hour 1
  6. Monitor closely for excessive BP drops (avoid >70 mmHg systolic reduction) 1
  7. Treat acute otitis media with antibiotics
  8. Optimize diabetes management given stress of acute illness 1
  9. Transition to oral therapy after 24-48h stabilization 1
  10. Screen for secondary causes after stabilization 1
  11. Monthly follow-up until BP controlled and organ damage regressed 1

References

1
Guideline

Hypertensive Emergency Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

MRI Imaging in Hypertensive Urgency with Unsteadiness

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

5
Research

Lupus nephritis-related chronic kidney disease.

Nature reviews. Rheumatology, 2024

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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