A Case of Bilateral Renal Artery Fibromuscular Dysplasia in a U.S. Soldier

Fibromuscular dysplasia (FMD) is a vascular disease characterized by abnormal cellular growth in medium-sized arteries progressing to stenosis, aneurysm, or arterial dissection. Renal and carotid artery involvement is common. FMD is not characterized by inflammation or atherosclerosis and predominantly impacts young women. Refractory hypertension is a common primary clinical manifestation of renal artery FMD. Severe or untreated FMD can lead to stroke, aneurysm rupture, or death. Despite the need for early diagnosis and aggressive management, FMD is frequently overlooked because of nonspecific presenting symptoms and perceived rarity. Diagnosis is made by imaging, often ultrasound or computed tomography (CT), though catheter-based angiography remains the gold standard. Because of the systemic nature of FMD, all patients require brain-to-pelvis cross-sectional imaging to screen for aneurysms and dissections. Treatment involves multidrug pharmacologic control of blood pressure; percutaneous transluminal angioplasty is reserved for refractory cases. Here, we present a 43-year-old female soldier with almost 2 decades of elevated blood pressure preceding her diagnosis. Failed treatment with multiple antihypertensive medications prompted further evaluation. Doppler ultrasound and CT angiography revealed bilateral renal artery stenosis with a characteristic "beaded" appearance, consistent with multifocal FMD. Management included a multidrug regimen of spironolactone, chlorthalidone, telmisartan, and amlodipine, resulting in blood pressure improvement without full resolution of hypertension. Our case highlights the importance of considering FMD in young, hypertensive patients to prevent delayed diagnosis of this potentially debilitating disease.