Asian Journal of Cardiology Research

Aim: This case study aims to emphasize the importance of maintaining a broad differential diagnosis when evaluating young hypertensive patients with retinal manifestations. The case emphasizes the need for early identification of secondary causes of hypertension such as polycythemia.

Case Presentation: A 33-year-old male with no prior comorbidities presented with blurred vision and severe hypertension (200/150 mmHg). Initial treatment with amlodipine was ineffective, requiring intensive care management with nitroglycerin infusion and a combination of oral antihypertensives, including cilnidipine, metoprolol, and prazosin. Laboratory evaluation revealed polycythemia (hemoglobin 19.9 g/dL) and hypercholesterolemia (266 mg/dL). Treatment included therapeutic venesection of 450 ml and lipid-lowering therapy. Following intervention, the patient’s blood pressure stabilized at 130/80 mmHg, and visual symptoms improved.

Discussion: Polycythemia increases blood viscosity, which elevates systemic vascular resistance and contributes to severe, refractory hypertension. This increased pressure causes mechanical and ischemic injury to retinal arterioles, manifesting as hypertensive retinopathy with hemorrhages and cotton wool spots. Management required a multi-drug regimen to address augmented sympathetic tone and hyperviscosity. Diagnostic workup included JAK2 mutation screening to differentiate between primary and secondary polycythemia, and negative autoimmune markers excluded inflammatory etiologies.

Conclusion: Hypertensive retinopathy in young adults without prior comorbidities should prompt immediate investigation for underlying hematological disorders like polycythemia. Early recognition and aggressive, integrated management of hypertension, lipids, and blood viscosity are vital to prevent permanent vision loss and systemic complications such as stroke or myocardial infarction.