Dr Sneha Amin1, Dr Hari Nandakoban
1South-Western Sydney Renal Unit, Liverpool, Australia
Biography:
Dr Sneha Amin is a third year renal advanced trainee, who is completing her training through the Central South-West Renal Network, NSW, Australia. She received her medical degree through Western Sydney University, completed her residency at Westmead Hospital and basic training in the Royal North Shore network. Her interests include chronic kidney disease, interventional nephrology and obstetric medicine.
Background:
Renovascular disease is a common cause of secondary hypertension in adolescents. Takayasu’s arteritis (TA) is an idiopathic large-vessel vasculitis that affects the aorta and its branches. The granulomatous inflammation results in arterial stenosis, thrombus, and aneurysm formation.
Case Report:
A 17-year-old female presented with a month of hypertension and headaches. The blood pressure was 150/85mmHg on both arms. She had a normal CT-brain. Her significant background included biopsy confirmed chronic recurrent multifocal osteomyelitis (CRMO) of the jaw at 7 years of age, managed with intermittent non-steroidal anti-inflammatories.
The cardiovascular and ophthalmic examination was unremarkable, with no renal bruits and normal peripheral pulses. The serum creatinine was 93umol/L, urea 5.5mmol and potassium 3.5mmol/L. The autoimmune panel was negative for ANA/ENA and ESR was 38mm/hr. The secondary hypertension screen was normal, with cortisol, thyroid function, renin aldosterone ratio and metanephrines assessed.
A renal doppler ultrasound reported a single renal artery perfusing each kidney with no evidence of renal artery stenosis. However due to her young age an MRI and MR-angiogram of the renal arteries followed by aorta was performed and this demonstrated an occluded left main renal artery with perfusion through an accessory artery to a mildly atrophic left kidney. The right renal artery was patent. The results were suspicious for TA. She was treated with prednisolone, infliximab and azathioprine. She was also commenced on perindopril, aspirin, pantoprazole and Bactrim.
Conclusions:
This case highlights that a high level of clinical suspicion is required for atypical presentations of hypertension. Although doppler ultrasound is recommended to reduce radiation exposure, it is operator and patient dependent on quality. Furthermore, CROM has been associated with other autoimmune conditions including TA.