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.
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).