Eight years old boy presented with complain of headache for a week with increasing thirst and polyuria. He was having altered sensorium and convulsions prior to admission. He appeared hypovolemic with feeble peripheral pulses, possibly contributed by the polyuria. His BP was 184/110 mmHg (95th\nP = 114/75). There was left sided hemiparesis along with 6th and 7th nerve palsy. Ophthalmological examination was consistent for hypertensive retinopathy. Investigations revealed hyponatremic, hypokalemic, metabolic alkalosis along with normal creatinine (Table ). USG with Doppler revealed bilateral hyper-echogenic kidneys with right relatively bigger (7.5 cm) than the left (6.2 cm) and suspected decreased blood flow in the left kidney. Renin and aldosterone was elevated. Digital subtraction angiography (DSA) of kidneys confirmed 90% stenosis of the left renal artery. MRI brain was consistent for PRES (Figure ).
The 5 years old boy presented with convulsions and vomiting for 6 d and obtunded sensorium for 3 d. Examination revealed elevated blood pressure (BP) (236/132 mmHg, 95th\nP = 108/71), brisk deep tendon reflexes with extensor planters and eye examination consistent with hypertensive retinopathy. He was having feeble peripheral pulses and was hypovolemic. He also had hyponatremic, hypokalemic, metabolic alkalosis with normal creatinine and elevated renin and aldosterone (Table ). Ultrasonography (USG) showed a small left kidney (5.7 cm) with loss of cortico-medullary distinction and enlarged hyperechogenic right kidney (7.1 cm). Computed tomography angiography (Figure ) confirmed occlusion of left renal artery distal to the origin, along with duplication of the artery. Magnetic resonance imaging (MRI) brain showed posterior reversible encephalopathy syndrome (PRES).