PM3048: A Peculiar Case of Malignant Hypertension Found After Intussuception Reduction

Introduction: Hypertension in the pediatric population is defined as blood pressure measurements above the 95th percentile for height, age and gender. When a patient has severe hypertension associated with organ failure of one or more organs, this is defined as malignant hypertension. According to the American Academy of Pediatrics, the prevalence of HTN among children and adolescents is estimated to be 3.5%. The prevalence of persistently elevated BP is also estimated to be close to 3.5% and tends to be higher in obese children and adolescents [2].

Case Description: The patient is a 14-month-male who presented to the pediatric intensive care unit postoperatively after laparotomy and reduction of intussusception. He initially presented with persistent abdominal pain and emesis. In the emergency department, the patient was found to have dehydration with leukocytosis. Ultrasound of the abdomen revealed acute intussusception. Radiology attempted air enema for reduction however were unsuccessful. Pediatric surgery was then consulted for operative repair. Postoperatively, the patient was found to have elevated blood pressure with the lowest pressure of 135/94 mmHg and altered mental status.

The patient was immediately started on a Nicardipine drip which was titrated with some improvements in blood pressure. The patient was evaluated by nephrology and found to have mild hydronephrosis, and elevated plasma catecholamine, and renin levels. An MIBG scan was then performed to evaluate for neuroendocrine causes which was negative. He continued with persistent hypertension requiring the addition of a labetalol drip.

The patient’s hospital course was complicated with Klebsiella bacteremia. Patient’s status worsened with the development of ARDS, septic shock, and purpura fulminans. Infectious disease, plastic surgery, and hematology also followed along during the admission. Over the following days, the patient tolerated transition to oral antihypertensives which he was discharged home with.

Discussion: The differential diagnosis of a patient with hypertension is vast and not just limited to renal pathology. In addition, the presence of postoperative hypertension is a rare and challenging occurrence requiring extensive work-up. Etiologies of hypertension in the pediatric population include inappropriate cuff size, post-operative pain, renovascular conditions, or a multi-factorial reason. In our case, the renovascular work-up revealed elevated catecholamines however imaging findings were benign making his hypertensive crisis a diagnostic challenge.

Conclusion: Current guidelines recommend routine BP screening annually for all children 3 y/o or older. For patients 3 y/o or older with risk factors for high BP such as obesity, renal disease, heart conditions, and/or diabetes, BP screening should be done at every medical encounter [2]. In this case, the patient's hypertension could have gone unnoticed for a prolonged period had he not needed an emergent procedure. It is important to keep a high index of suspicion for abdominal pathologies including intussusception in pediatric patients with hypertension.