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Cause of Secondary Hypertension

Mrs. S, 24 y/o female, had off/on history of headaches and palpitations since 10 years of age. She used to go to doctors who always told her that she had high blood pressure. Her complaints were increased when she was 15 years of age. Her first reported BP was more than 110 diastolic when she was 20 years old. She was neither treated nor investigated. She never had complaints of dyspnea, chest pain, decrease vision, urinary problems or swelling. Her mother was also hypertensive and died of ischemic heart disease. There was no history of any unusual drug intake.

She got married 1 year back, and during pregnancy beside headaches, she also started complaining of burning micturation, especially at 4th - 5th months. She was found to have UTI and treated. She developed these complaints 3 times during her pregnancy.

At 6th month, she came to Gyne department and admitted for urinary tract infection and high blood pressure. UTI was proven from Urine R/E. Her recorded BP was 220/130 mmHg. She was put on Tab. Methyl Dopa 1gm/day, and later on Tab. Nifedipine 80mg/day was also added, after seeing minimal response with initial treatment. With that combination therapy, BP came at 190/120 mmHg. IV nitrates were also tried to lower her BP. But, due to uncontrolled BP, spontaneous abortion took place, and she was referred to MU-2 for management on 16th Dec. 2002.

On examination in MU-2, she was an average built young lady, conscious and cooperative. Her pulse was 82/min, with no radio-radial & radio-femoral delay and no palpable vessel walls. Her height was 5’2” and weight 45kg. There was no facial rash, bruises, swelling, acne, hair loss, hirsutism, and edema. Her apex beat was not displaced, heart sounds were normal, and chest was clear. Abdomen was soft, with no visceromegaly, palpable kidneys and renal artery bruit. Her CNS examination was also normal.

She was investigated :-

Blood CP = Normal (Hb = 11.5gm/dl)
Na/K = 140/3.9 mmol/L
Random Blood Glucose = 90mg/dl
Urine R/E = Normal
S. Urea = 26mg/dl
Ultrasound abdomen= Left kidney smaller in size (5.6x3.1cm) – may be congenital
ECG = Normal, no LVH
Fundus = Normal, no hypertensive changes
Echocardiography = Normal, no hypertrophy,
Grade I AR, EF 61%
S. Creatinine = 0.8mg/dl
Creatinine Clearance = 16 ml/minute
(77-117 ml/min)
Urine Creatinine = 19.5 mg/dl

No evidence of TOD found. Hypertension remained in Stage III Risk B. She was put on Tab. Nifedipine 80mg/day and Tab. Atenolol 100mg/day, and her BP came at 150/90.

Thinking of renal artery stenosis, she was advised Renal Scan.

Baseline 99mTc-DTPA Dynamic Renal Scan = Right kidney – fair perfusion
Left Kidney – Delayed and reduced Perfusion, kidney appears small & shrunken
Left renogram – flat curve with markedly reduced uptake

Post-Captopril 99mTc-DTPA Dynamic Renal Scan
(Scintigraphy) GFR:
Baseline:
Right Kidney = 52ml/min Left Kidney = 06ml/min
Post-Captopril
Right Kidney = 68ml/min Left Kidney = 18ml/min

Do not reveal any evidence of renal artery stenosis

Other tests which were done:

T3 1.69 ng/ml (0.6 – 1.81)
T4 9.5 ug/dl (3.2 – 12.6)
TSH 1.16 uIU/ml (0.4 – 4.0 uIU/ml)

Next possibility thought was Pheochromocytoma, a cause of secondary hypertension:

Conc. of VMA in urine 3.6 mg/dl
Total urinary VMA 2.8 mg/24 hrs (1.9 – 9.

PROBLEMS

1. What else could be the cause of Sec. HTN ?
2. She needs a successful pregnancy, what treatment options are available ?