Renovascular Hypertension in a Pediatric Patient
Patient Presentation
A three year old male, E.C., is brought to the ER with acute left sided facial palsy. E.C.’s mother states her son has been irritable over the last few weeks but she attributed this to her attempts to potty-train him. At his last check-up, two weeks ago, E.C. was said to have all normal findings except the RN was unable to obtain an “accurate” BP. The automatic BP cuff kept reading “error.” E.C.’s mother was told this was because her son was upset. His current VS include: 36.6 degrees C, HR 80 bpm in sinus rhythm, BP 180/110, RR 22, and oxygen saturation of 99% on RA. On assessment, E.C. has a normal neurologic exam except for his left sided facial palsy. He has no cardiac murmur and has 2+ pulses on both upper and lower extremities. His lungs are clear to auscultation. Labs are collected and E.C. is brought to CT to check for a cranial bleed. After CT, he is sent to the PICU for further testing and observation.
Differential Diagnoses
Renovascular hypertension, coarctation of the aorta, trauma, stroke, hypertension
Diagnosis
E.C. is placed on a cardiac monitor, which continues to show a normal HR and rhythm. The CT scan is negative for a cranial bleed and E.C.’s neurologic exam remains stable (except for the facial palsy), thus trauma is ruled out. The following labs are all normal: CBC, serum electrolytes, BUN, creatinine, urinalysis and urine culture. The physician places an arterial line for continuous monitoring of E.C.’s BP, which remains high (greater than 160/100). E.C. is started on a continuous gtt of an antihypertensive agent. The physicians rule out coarctation of the aorta after a normal chest x-ray and echocardiography. Since one of the most common causes of hypertension in children is renal disease (even though renal panels are usually normal in children with renovascular hypertension), E.C. must undergo an ultrasound of the kidneys and abdomen followed by a magnetic resonance angiography (MRA) of the kidneys. These results indicate a unilateral renal artery stenosis and E.C. is diagnosed with renovascular hypertension with unknown etiology. The renal artery stenosis caused renal ischemia, which activated the renin-angiotensin-aldosterone system thus causing vasoconstriction and volume retention and ultimately an elevated blood pressure. E.C.’s facial palsy and irritability appear to be neurologic symptoms of his extremely high BP.
Treatment
The goal for E.C.’s treatment is the correction of his hypertension and the preservation of renal function. E.C. is started on PO propranolol (adrenergic blocking agent) and hydrochlorothiazide (diuretic) to decrease his BP. The treatment of choice for E.C. is surgical revascularization, but the surgeon would like to wait until E.C. is bigger and older.
Outcome
E.C. was transferred out of the PICU to the acute care floor once his blood pressure remained in the 120s/70s consistently with oral antihypertensives. E.C.’s facial palsy improved with therapy and he was transferred home after a couple of weeks. His BP was managed as an outpatient by the nephrology clinic and he will undergo surgical renal revascularization as a four year old.