Cardiac echocardiography revealed eccentric left ventricular hypertrophy and hypokinesis of ventricular septum and inferior wall of the left ventricle with an ejection fraction of 44%. presented with hypertensive crisis and cardiogenic pulmonary edema, and acute renal failure. Her extremely elevated blood pressure was refractory to multiple antihypertensive medications, hemodialysis and plasmapheresis, until the administration of eculizumab. The patient, a 56-year-old woman, was well until she caught a cold about 1 month before the incident during her travel to the U.S.A. Fatigue and dizziness developed in the next few weeks. She was sent to the emergency department of a medical center in Sivelestat sodium salt the U.S.A. due to productive cough with pink-colored sputum and progressive orthopnea for 2 days. On examination, she was in respiratory distress. She had a body temperature of 36.7 C, a blood pressure of 266/162 mmHg, a pulse rate Sivelestat sodium salt of 148 beats per minute, a respiratory rate of 28 breaths per minute, and an oxygen saturation of 87% on room air. Pale conjunctiva with jugular vein distention were noted. Auscultation of the chest revealed bilateral basal rales and expiratory wheezing. There was also grade 2+ edema on both legs. Acute decompensated heart failure with pulmonary edema was impressed. Oxygen supplementation with continuous positive airway pressure (CPAP) was then administered. The patients serial blood examination Sivelestat sodium salt results are shown in Table 1. Blood count upon admission revealed hemoglobin 7.5 g/dL, platelet count 68,000/L and poor renal function (creatinine 8.9 mg/dL). Electrocardiogram revealed sinus rhythm, nonspecific ST-T wave abnormalities in precordial leads, and evidence of left ventricular enlargement. Chest radiograph and chest computed tomography findings demonstrated cardiomegaly, bilateral central opacities, and massive right-sided pleural effusion with passive atelectasis. Furosemide and nitroglycerin were intravenously administered. However, 1 hour later, respiratory failure developed; thus, endotracheal intubation was performed with subsequent mechanical ventilatory support. Intermittent hemodialysis (for 7 times) was also arranged due to the presence of acute pulmonary edema. Subsequent blood examination showed negative Coombs test result, low haptoglobin level ( 10 mg/dL), and reticulocytosis (0.141 1012/L, 4.38%). Red blood cell (RBC) morphology revealed at least 2 to 3 3 schistocytes per high-power field. Since TMA was suspected, plasmapheresis was performed twice as thrombotic thrombocytopenic purpura (TTP) could not be ruled out. Due Sivelestat sodium salt to improvement in clinical conditions, the patient was extubated on Day 4. She was later transferred back to Taiwan and admitted to our hospital for further evaluation and management on Day 13. Table 1 Serial laboratory results at admission and after discharge thead VariableReference rangeDay 0Day 32Day 35Day 59*Day202# /thead White-cell count (/mm3)4000-10000940011200730054005200Hemoglobin (g/dl)Men: 13-177.58.910.811.513.2?Woman: 12-15?????Platelet (/mm3)150000-40000068000172000189000241000207000INR0.9-1.210.94—aPTT (sec)20-403019.6—Reticulocytes (%)0.6-2.14.38—-Hepatoglobin (mg/dL)30-200 1010.381.3112.981.2LDH (U/L)50-150922200249241216GOT (U/L)4325049—-GPT (U/L)5-3525—-Total bilirubin (mg/dL)0.3-2.02.4—-Direct bilirubin (mg/dL)0-0.30.3—-Alk-P (U/L)50-10084—-Total protein (mg/dL)6.0-8.0—-Albumin (g/dL)3.5-5.53.5–4.34.3Urea nitrogen (mg/dl)433338533635256Creatinine (mg/dl)0.8-1.38.95.736.984.632.69eGFR (mL/min/1.73 m2) 904.868.06.01018Sodium (mmol/L)136-145126132136138136Potassium (mmol/L)3.5-5.03.53.63.83.54Calcium (mg/dl)9.0-10.5-9.89.59.89.7Phosphorus (mg/dl)3.0-4.5-3.23.43.64.2bicarbonate Col4a2 (mmol/L)24-26-23192623NT-proBNP (pg/ml) 12514500—-C-reactive protein (mg/dL) 0.50.3—-Troponin I (ng/ml) 0.30.35—- Open in a separate window * After 4 doses of Eculizumab (post induction phase) injection. # After 15 doses of Eculizumab injection. Alk-P, alkaline phosphatase; aPTT, activated partial thromboplastin time; eGFR, estimated glomerular filtration rate; GOT, glutamate oxaloacetate transaminase; GPT, alanine aminotransferase; INR, international normalized ratio; LDH, lactate dehydrogenase; NT-proBNP, N-terminal pro-brain natriuretic peptide. Her blood pressure remained high despite multiple antihypertensive medications (Carvedilol 25 mg 1# BID, Nifedipine 30 mg 1# Q12H, Azilsartan 40 mg 1# HS, Doxazosin 4 mg 1# Q12H). Hemodialysis (Day 15) and plasmapheresis (Day 16) were continued. There was no evidence of hypertensive retinopathy upon ophthalmological examination. Initial laboratory tests showed that urea was 44 mg/dL, creatinine 5.16 mg/dL, sodium 140 mmol/L, potassium 4.4 mmol/L, free calcium 1.15 mmol/L (reference range: 1.13-1.31 md/dL), LDH 393 U/L, total bilirubin 0.56 mg/dL, and direct bilirubin 0.2 mg/dL. Urinalysis showed 1+ protein, 3-5 erythrocyte per high-power field, and daily urine albumin excretion of 0.3916 g/day. Blood count was as following: hemoglobin 9 g/dL, platelet count 204,000/L, reticulocyte count 2.78% (reference range: 0.6-2.1%). Haptoglobin was 9.5 mg/dL (reference range: 30-200 md/dL) and both direct.