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: avramanan@hotmail.com

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

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