The 12 years old boy was admitted with headache for 1 mo, increased thirst, polyuria for 15 d and obtunded sensorium for 4 d. There was a documented decrease in weight of 800 g over the last 2 wk, possibly because of the polyuria. BP was 244/166 mmHg (95th\nP = 121/79). Ophthalmological examination was consistent with hypertensive retinopathy. Investigation showed hyponatremic, hypokalemic, metabolic alkalosis and normal creatinine (Table ). USG doppler revealed “parvus- tardus” like flow in left renal artery, with enlarged hyper-echogenic right kidney. MRI brain was consistent with PRES. Digital subtraction angiography confirmed left renal artery stenosis (Figure ).\nAll three cases had high urinary sodium indicating natriuresis as the cause of the hyponatremia (Table ).\nThe patients were diagnosed to have HHS presenting as hypertensive emergency. They were initially managed with Labetalol infusion and thereafter switched to oral anti-hypertensives (combination of Nifedipine sustained release, Hydralazine and Beta Blocker). Case 1 and 2 were given 3% NaCl and all required potassium supplements. Electrolyte abnormalities gradually corrected with normalization of BP.\nCase 1 was advised PTA but was lost to follow up after 3 mo till when he was hypertensive (132/86 mmHg) despite being on Enalapril, Nifedipine and Atenolol. His electrolytes had normalized but he continued to have significant proteinuria; case 2 underwent percutaneous transluminal balloon angioplasty (PTA), which restored normal blood flow. His sodium normalized in 2 wk and urinalysis by 8 wk. At last follow up (20 mo) he remains off anti hypertensive with normal BP and renal profile; Case 3 underwent a failed balloon angioplasty of left renal artery followed by successful renal artery stenting. At 9 mo follow up, his electrolytes and urinalysis had normalized and he had normal BP (110/70 mmHg) on 1.25 mg of Enalapril. The USG changes in the contra-lateral kidney also normalized by last follow up for Case 2 and 3.
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 ).