eng Science and Education Publishing American Journal of Medical Case Reports 2374-216X 2016-02-03 4 1 31 34 10.12691/ajmcr-4-1-9 AJMCR2016419 article Pramod Theetha Kariyanna drtkpram@gmail.com 1 Apoorva Jayarangaiah 2 Robert Adrah 3 Abhishek Sharma 4 Debabrata Sen 4 Department of Internal Medicine, State university of New York (SUNY)- Downstate Medical center, Brooklyn, New York, U.S.A. Department of Internal Medicine, Marshfield Clinic- St. Joseph Hospital, Marshfield, Wisconsin, U.S.A. Department of Internal Medicine, Brookdale University Hospital and Medical Center, Brooklyn, New York, U.S.A. Division of Cardiology, Department of Internal Medicine, State university of New York (SUNY)- Downstate Medical center, Brooklyn, New York, U.S.A. Pickering syndrome is an under recognised cardio-renal syndrome where life threatening flash pulmonary edema develops in the setting of diastolic dysfunction of the heart. Renal artery stenosis induced activation of sympathetic nervous system and renin-angiotensin-aldosterone system result in fluid retention; such fluid retention in the setting of diastolic dysfunction results in flash pulmonary edema. Most patients who present with pickering syndrome have normal coronary circulation and left ventricular systolic function. We here present a case of pickering syndrome that was precipitated by initiation of angiotensin converting enzyme inhibitor therapy in a patient with undiagnosed unilateral renal artery stenosis. The incidence of flash pulmonary edema decreases on revascularization of renal artery stenosis. Underlying renal artery stenosis should be suspected in a patient with recurrent flash pulmonary edema as such patients merit from revascularization of renal artery stenosis. To the best of our knowledge we are the first to report angiotensin converting enzyme inhibitors as a precipitator of pickering syndrome. http://pubs.sciepub.com/ajmcr/4/1/9/ajmcr-4-1-9.pdf pickering syndrome renal artery stenosis diastolic dysfunction of heart angiotensin converting enzyme inhibitors renal artery revascularization