Acute Pulmonary Oedema with Normal Left Ventricular Function in a Patient with Resistant Hypertension--what is the Likely Diagnosis?

We report the case of a 75-year old woman who presented with shortness of breath and haemoptysis. She had been treated for presumed essential hypertension for many years. On admission she was found to be severely hypertensive. Chest X-ray showed pulmonary oedema. However, an echocardiogram reported good systolic ventricular function. Her hypertension and pulmonary oedema did not respond to medical treatment necessitating intubation. A CT angiogram identified the cause--undiagnosed bilateral severe. We discuss this increasingly common condition that is difficult to manage and easily missed.