A TALE OF TWO SYSTEMS: MALIGNANT HYPERTENSION PRESENTING WITH PAINLESS HEMATURIA AND ACUTE PULMONARY EDEMA — A DIAGNOSTIC ODYSSEY

Malignant hypertension is an acute, life-threatening form of severe hypertension characterized by rapidly progressive target-organ damage involving the kidneys, retina, central nervous system, and cardiovascular system. Early recognition is critical to prevent irreversible injury. We report the case of a previously healthy 35-year-old man presenting with one week of painless macroscopic hematuria followed by sudden-onset dyspnea with pink frothy sputum. Evaluation revealed severely elevated blood pressure, grade 4 hypertensive retinopathy, acute pulmonary edema, proteinuric hematuria, hypokalemia, and acute kidney injury. The patient required non-invasive ventilation, intravenous antihypertensive therapy, and multiple sessions of hemodialysis. This case highlights the importance of recognizing hematuria as an early manifestation of hypertensive renal microangiopathy and emphasizes the multi-system involvement that characterizes malignant hypertension.