Background: Renal angiomyolipoma (AML) is a rare benign tumor of the kidney that can occur as a sporadic lesion or a part of tuberous sclerosis. Renal disease is the most common cause of death in adults with tuberous sclerosis complex. 

Case presentation: This is a 77-year-old female with a history of hypertension, hyperlipidemia, unclear history of left nephrectomy in 1999 presented with progressive shortness of breath towards the end of any activity associated with palpitation. Exam was not significant except for high blood pressure (BP) 160/80. 

Decision making: Given her multiple risk factors, ischemic heart disease was one of the top differentials. Since her resting EKG didn't show ischemic changes, plan was to get a stress echocardiogram and optimize risk factors control. On follow up, she remained hypertensive on Amlodipine 10 mg and Coreg 3.125 with BP of 173/75. Stress echocardiogram was not conclusive, so we decided to pursue CT coronary angiogram. Although it didn't show significant lesions in her coronaries, it gave us guidance in the rest of her care plan. CT showed multiple lesions in her lungs (Figure A) and right kidney representing lymphangiomyomatosis. The largest mass in the kidney measured up to 7.6 x 9.0 cm (Figure B). Patient was diagnosed by tuberous sclerosis and was followed up by pulmonology and nephrology after that. Renal angiomyolipoma was confirmed by MRI. Figure C On follow-up, the decision was to do embolization of the renal angiomyolipoma. Creatinine remained stable after the procedure. On further follow-ups, her BP was more controlled 136/74 on amlodipine alone, and started going down on the dose. She reported feeling well and symptom-free.

Conclusion: Renal angiomyolipoma as a part of tuberous sclerosis is a rare cause of secondary hypertension. Embolization of angiomyolipoma is effective in controlling BP.