Renal hypertension: an unusual cause for a common problem
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IMAGES IN PEDIATRICS Renal hypertension: an unusual cause for a common problem M. Amjad Khan & A. V. Ramanan & Paula Murphy & Moin A. Saleem Received: 9 December 2012 / Accepted: 22 January 2013 / Published online: 1 February 2013 # Springer-Verlag Berlin Heidelberg 2013 Abstract A 9-year-old girl with longstanding headaches presented acutely with rash, which disappeared quickly on treatment with oral phenoxymethylpenicillin. It was attributed to streptococcal infection as group A strepto- coccus was isolated from throat swab. She was inciden- tally found to have high blood pressure on routine screening on admission. Subsequently, ‘fibromuscular dysplasia’ was confirmed on renal angiogram, which showed a characteristic beaded appearance. It is a good clinical practice to check blood pressure in any child seen for whatever reason. Keywords Blood pressure . Hypertension . Fibromuscular dysplasia . Paediatrics . Headache A 9-year-old girl with longstanding headaches presented acutely with rash. The rash disappeared quickly on treatment with oral phenoxymethylpenicillin and was attributed to streptococcal infection as group A strepto- coccus was isolated from throat swab. She was inciden- tally found to have high blood pressure on routine screening on admission (160 mmHg systolic). Here sys- tolic blood pressure during admission ranged from 130 to 160 mmHg. Anti-hypertensive medications were in- troduced and gradually increased until blood pressure was controlled (less than 130 mmHg systolic) with triple agent therapy including amlodipine, metoprolol and methyldopa. Extensive blood tests including haematological, bio- chemical, urinary, endocrine and autoimmune screening were normal. Chest radiograph and cardiac echo were reported normal. Renal ultrasound showed an abnormal Doppler trace on the right side (Fig. 1a). Subsequently, a renal angiogram was arranged which showed a characteristic beaded appearance of ‘fibromuscular dysplasia’ (Fig. 1b), and right renal angioplasty was performed. Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic vascular disease that involves small- and medium-sized arteries [1, 2]. Histopathology and angiogra- phy confirm the diagnosis. Treatment is recommended only in symptomatic cases. It is a good clinical practice to check blood pressure in any child seen for whatever reason and important to investigate fully when sustained hypertension is discov- ered. The possibility of renovascular disease should always be considered in any child with significant M. A. Khan : A. V. Ramanan (*) Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8AE, UK e-mail: [email protected] M. A. Saleem Department of Paediatric Nephrology, Bristol Children’ s Hospital, Bristol, UK P. Murphy Department of Radiology, Bristol Royal Infirmary, Bristol, UK Eur J Pediatr (2013) 172:711–712 DOI 10.1007/s00431-013-1957-z
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Transcript of Renal hypertension: an unusual cause for a common problem
IMAGES IN PEDIATRICS
Renal hypertension: an unusual cause for a common problem
M. Amjad Khan & A. V. Ramanan &
Paula Murphy & Moin A. Saleem
Received: 9 December 2012 /Accepted: 22 January 2013 /Published online: 1 February 2013# Springer-Verlag Berlin Heidelberg 2013
Abstract A 9-year-old girl with longstanding headachespresented acutely with rash, which disappeared quicklyon treatment with oral phenoxymethylpenicillin. It wasattributed to streptococcal infection as group A strepto-coccus was isolated from throat swab. She was inciden-tally found to have high blood pressure on routinescreening on admission. Subsequently, ‘fibromusculardysplasia’ was confirmed on renal angiogram, whichshowed a characteristic beaded appearance. It is a goodclinical practice to check blood pressure in any childseen for whatever reason.
Keywords Blood pressure . Hypertension . Fibromusculardysplasia . Paediatrics . Headache
A 9-year-old girl with longstanding headaches presentedacutely with rash. The rash disappeared quickly ontreatment with oral phenoxymethylpenicillin and wasattributed to streptococcal infection as group A strepto-coccus was isolated from throat swab. She was inciden-tally found to have high blood pressure on routinescreening on admission (160 mmHg systolic). Here sys-tolic blood pressure during admission ranged from 130
to 160 mmHg. Anti-hypertensive medications were in-troduced and gradually increased until blood pressurewas controlled (less than 130 mmHg systolic) withtriple agent therapy including amlodipine, metoprololand methyldopa.
Extensive blood tests including haematological, bio-chemical, urinary, endocrine and autoimmune screeningwere normal. Chest radiograph and cardiac echo werereported normal. Renal ultrasound showed an abnormalDoppler trace on the right side (Fig. 1a).
Subsequently, a renal angiogram was arranged whichshowed a characteristic beaded appearance of ‘fibromusculardysplasia’ (Fig. 1b), and right renal angioplasty was performed.
Fibromuscular dysplasia (FMD) is a non-inflammatory,non-atherosclerotic vascular disease that involves small- andmedium-sized arteries [1, 2]. Histopathology and angiogra-phy confirm the diagnosis. Treatment is recommended onlyin symptomatic cases.
It is a good clinical practice to check blood pressurein any child seen for whatever reason and important toinvestigate fully when sustained hypertension is discov-ered. The possibility of renovascular disease shouldalways be considered in any child with significant
M. A. Khan :A. V. Ramanan (*)Department of Paediatric Rheumatology, Bristol Royal Hospitalfor Children, Upper Maudlin Street,Bristol BS2 8AE, UKe-mail: [email protected]
M. A. SaleemDepartment of Paediatric Nephrology, Bristol Children’s Hospital,Bristol, UK
P. MurphyDepartment of Radiology, Bristol Royal Infirmary, Bristol, UK
Eur J Pediatr (2013) 172:711–712DOI 10.1007/s00431-013-1957-z
hypertension, and careful evaluation of routine testssuch as the Doppler renal ultrasound can give crucialclues to the diagnosis.
Conflict of interest None
References
1. de Carvalho Pontes T, Rufino GP, Gurgel MG, de MedeirosAC, Freire EAM (2011) Fibromuscular dysplasia: a differentialdiagnosis of vasculitis. Rev Bras Reumatol 52(1):66–74
2. Plouin PF, Perdu J, La Batide-Alanore A, Boutouyrie P,Gimenez-Roqueplo AP, Jeunemaitre X (2007) Fibromusculardysplasia. Orphanet J Rare Dis 2(28):6
Fig. 1 a The peak systolicvelocity in the main right renalartery is approximately 1.5 m/s.The spectral trace in the arcuatearteries on the right has a parvustardus (slow rising) appearancesuggestive of renal arterystenosis. b Pre-angioplastydigital subtraction angiogramshowing typical beadedappearance. There is extensivefibromuscular dysplasia in theright kidney. Probably, there isinvolvement of small branch toinferior pole of the left kidney
712 Eur J Pediatr (2013) 172:711–712
