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Severe hypertension in a patient with unilateral obstructive hydronephrosis and renal artery stenosis
458
The Journal of Pediatrics September 1978
Brief clinical and laboratory observations
two of the 70 children had solitary lesions; eight ch ildren had two to four abscesses. Boys predominated over girls by a 2: I ratio, and children under ten years accounted for 80% of the cases . The thigh was the most common site , followed by the calf or leg , buttock, arm, scapula, and chest wall. Staphylococcus aI/reus was present in 36 of 41 (88%) positive cultures. In follow-up examination of 22 patients, none had developed clinical or radiologic evidence of osteomyelitis. Trauma is frequently mentioned as a predisposing event. Chacha 1 noted that only 21 % had a definite history of trauma. However, in a study of muscle abscesses in army recruits, Ashken and Cotton" correlated trauma with 66% of the cases and made these important observations: (I) the incidence of abscesses increased as the severity of the phys ical training progressed, (2) the abscesses were three times more common on the dominant right side than on the left, and (3) the intramuscular abscess cavities often contained histologic evidence of extravasation of blood (hematoma). The role of trauma receives additional support from the 2:1 male predominance, since serious accidental injuries occur two to three limes more often in boys than in girls" In addition, the association of pyogenic muscle abscess with trauma has been well documented in experimental studies in animals. Miyake" demonstrated that rabbits given intrave nous inoculations of staphylococci would develop pyogenic abscesses only in skeletal muscles which had been damaged by mechanical pinch-
' ing. Staphylococcal pyomyositis has now been des cribed in five children from three diverse geographic regions of the United States. Each of the three previously reported patients" , had single intramuscular abscesses, whereas the two from San Antonio had multiple lesions. Two of
the five children had recent serious accidents; the other three had less injurious falls. The diagnosis of pyomyositis should be considered in any febrile child with unexplained localized muscle pain, especially if there is a history of recent trauma, and a search should be made for a mass (or masses) in commonly involved mu scles. Aspiration of a suspicious mass may provide a rapid diagnosis, but incision with the patient under general anesthesia is required to drain larger abscesses. Both patients described in this report were also treated intravenously with a semisynthetic penicillin until clinical improvement was evident, at which time they were given oral antibiotic medication for two weeks. Dr. Gea Miller assisted in gathering information about Patient l. REFERENCES I.
Chacha PB: Muscle abscesses in children, in Urist MR. editor: Clinical orthopedics and related research, no 70, Philadelphia, 1970. JP Lippincott Company, Chapter 21, pp ' 174-180,
Marcus RT, and Foster WD: Observations on the clinical features, aetiology and geographical distribution of pyomyositis in east Africa, East Afr Med J 45: 167, 1968. 3. Traquair RN: Pyomyositis, 'J Trap Med Hyg 50:71, 1947. 4. Echeverria P, and Vaughn MC: "Tropical pyomyositis," Am J Dis Child 129:856, 1975. 5. Altrocchi PH: Spontaneous bacterial myositis, JAMA
2,
217:819, 1971. 6, Ashken MH, and Cotton RE: Tropical skeletal muscle abscesses (pyomyositis tropicans), Br J Surg 50:846, 1963. 7, Wheatley OM: Childhood accidents: prevention and treatment, Pediatr Ann 6:12. 1977.
8, Miyake H: Beitrage zur Kenntnis der sogenannten Myositis infectiosa, Mitt Grenzgeb Med Chir 13:155, 1904,
Severe hypertension in a patient with unilateral obstructive hydronephrosis and renal artery stenosis Matti Uharl, M.D.,· Mikko Remes, M .D., Peter Lanning, M.D., and Juhani Sepplinen, M.D ., 011111,
Finland
PERSISTENT, moderate, or severe hypertension in children is usually secondary in nature, and renal diseases are the most common causes.' In the series of Gill and
From the Departmentsof Pediatrics and Diagnostic Radiology, University of 01//1/, •Reprint address: Department oj Pedlatrtcs, University of 011111, 90210 Oulu 22, Finland.
coworkers,' obstructive uropathy and renovascular disorders were together the cause of 12% of all cases of hypertension in children. These diso rders can occur at the same time, but we have found only one report of hydronephrosis and renovascular disorders occurring independently but simultaneously.' We have recently treated a l2-year-old boy with renal artery stenosis and 0022-3476/78/0393-0458$00.20/0 e 1978 The C. V, Mosby Co.
Brief clinicaland laboratory observations
Volume 93 Number 3
simultaneous unilateral obstructive hydronephrosis due to pelvoureteral stenosis. CASE REPORT
A l2-year-old boy who had for months been having headaches and nausea was referred to the Department of Pediatrics, University of Oulu. The patients was of average size-height 154 em and weight 37 kg. A physical examination showed high blood pressure (210/140-170/120 mm Hg), but otherwise normal findings. There were no vascular changes in the fundi of the eyes. The abdomen was not auscultated. When measured previously in connection with an operation nine years earlier, the blood pressure had been normal. Abbreviation used IVP: intravenous pyelography Laboratory tests showed the blood pH to be 7.48; serum Na 145 mEq/l; K 3,2 mKq/l; creatinine 0.8 rng/dl. Peripheral renin activity (measured by using radioimmunoassay) was 10.3 ng/ ml/hr (normal values in this laboratory are 1.0 to 4.6 ng/ml/hr for this age), and the renin values in the vena cava and right and left renal veins were still higher-31.0, 58.0 and 25.9 ng/ml/hr, respectively. Peripheral renin activity was measured before antihypertensive medication, but the renal vein samples were taken while he was receiving medication. The ratio between the renal vein renin values was thus 2.2. Values for hemoglobin and vanillymandelic acid were normal. Because of the high blood pressure and symptoms, treatment with antihypertensive drugs was started immediately. During the first day, diazoxide was given, resulting in a drop in blood pressure to 1501105 mm Hg. The next day an electroencephalogram was performed, showing more low frequencies than normal; this abnormal finding has been seen in patients with hypertensive crisis. Intravenous pyelography demonstrated obstructive hydronephrosis in the right kidney due to .pelvoureteral stenosis, and renal arteriography disclosed a renal artery stenosis on the same side. The high blood pressure was subsequently treated with hydralazine and thiazide diuretics given orally. Because of the simultaneous hydronephrosis, renal artery stenosis, and hypertension, it was decided to perform nephrectomy; this was done two weeks after the initial diagnosis. The operative findings were the same as found by IVP and arteriography, namely hydronephrosis and renal artery stenosis.
DISCUSSION There are many causes of renal hypertension,' but hydronephrosis and renovascular disorders are not usual in children.' Bilateral or unilateral hydronephrosis can cause hypertension." • In all reports of unilateral obstructive hydronephrosis, renovascular disorders have not been excluded.' It seems likely that the hypertension in our patient was caused both by the renal artery stenosis and by the hydronephrosis." 6, 7 All children with unexplained severe hypertension should be examined by IVP. If in a patient with severe
459
hypertension a mild abnormality is found in the IYP, renal arteriography should be considered since an IVP does not always show all the conditions able to cause hypertension. According to our earlier experience, hypertension in children with unilateral hydronephrosis is not usually severe." Thus the severity of the hypertension in this patient gave rise to a suspicion of some other primary cause than unilateral hydronephrosis, Since renal hypertension is mediated mainly via the renin-angiotensin-aldosterone system, estimations of peripheral renin activity can give clues to possible renal origin.! Our patient had signs of secondary hyperaldosteronism, high renin activity, and a mild hypokalemic alkalosis. In unilateral renal diseases renin levels in the peripheral blood may be normal, but selective renin estimations from the renal veins show high renin values from the diseased kidney.' Renal vein ratios of 1.5: I or greater have been proposed as necessary before recommending surgery.' Godard" has shown, however, that in children the renin estimations probably do not have the same predictive value and that surgical treatment should be tried even in patients with negative results from the renin ratios. Similar results have been reported in adults. '0 The predictiveness of this ratio is difficult to estimate, and not clearly resolved. In our patient, the renal vein renin ratio w~s 2.2, and surgical treatment by nephrectomy was successful. REFERENCES I.
2.
3.
4.
5. 6.
7. 8. 9.
10.
Gill D, daCosta B, Cameron J, et al: Analysis of 100 children with severe and persistent hypertension, Arch Dis Child 51:951, 1976. Presto AJ, and Middleton RG: Cure of hypertension in a child with renal artery stenosis and hydronephrosis in a solitary kidney, J Urol 109:98, 1973. Loggie J, and Mcfinery P: Hypertension in childhood and adolescence, ill Rubin M, and Barrat T, editors: Pediatric nephrology, Baltimore, 1975, The Williams & Wilkins Company. pp 417-453. Weidmann P, Beretta-Piccoli C, Hirsch D, et al: Curable hypertension with unilateral hydronephrosis. Studies on the role of circulating renin, Ann Intern Med 87:437, 1977. Houston W: Hypertension due to hydronephrosis: Relief after nephrectomy, Br Med J 2:644, 1956. Goldblatt H, Lynch J, Hanzal RF, et al: Studies on experimental hypertension. The production of persistent elevation of systolic blood pressure by means of renal ischemia, J Exp Med 59:347, 1934. Miller S, and Lubahn J: Clinical features of renovascular hypertension in infancy, Pediatrics 56:108, 1975. Uhari M, and Koskimies 0: A survey of 164Finnish children and adolescents with hypertension (to be published). Godard C: Predictive value of renal-vein renin measurements in children with various forms of renal hypertension. An international study, Helv Pediatr Acta 32:49, 1977. Maxwell M, Marks L, Lupu A, et al.: Predictive value of renin determinations in renal artery stenosis, JAMA 238:2617, 1977.
The Journal of Pediatrics September 1978
Brief clinical and laboratory observations
two of the 70 children had solitary lesions; eight ch ildren had two to four abscesses. Boys predominated over girls by a 2: I ratio, and children under ten years accounted for 80% of the cases . The thigh was the most common site , followed by the calf or leg , buttock, arm, scapula, and chest wall. Staphylococcus aI/reus was present in 36 of 41 (88%) positive cultures. In follow-up examination of 22 patients, none had developed clinical or radiologic evidence of osteomyelitis. Trauma is frequently mentioned as a predisposing event. Chacha 1 noted that only 21 % had a definite history of trauma. However, in a study of muscle abscesses in army recruits, Ashken and Cotton" correlated trauma with 66% of the cases and made these important observations: (I) the incidence of abscesses increased as the severity of the phys ical training progressed, (2) the abscesses were three times more common on the dominant right side than on the left, and (3) the intramuscular abscess cavities often contained histologic evidence of extravasation of blood (hematoma). The role of trauma receives additional support from the 2:1 male predominance, since serious accidental injuries occur two to three limes more often in boys than in girls" In addition, the association of pyogenic muscle abscess with trauma has been well documented in experimental studies in animals. Miyake" demonstrated that rabbits given intrave nous inoculations of staphylococci would develop pyogenic abscesses only in skeletal muscles which had been damaged by mechanical pinch-
' ing. Staphylococcal pyomyositis has now been des cribed in five children from three diverse geographic regions of the United States. Each of the three previously reported patients" , had single intramuscular abscesses, whereas the two from San Antonio had multiple lesions. Two of
the five children had recent serious accidents; the other three had less injurious falls. The diagnosis of pyomyositis should be considered in any febrile child with unexplained localized muscle pain, especially if there is a history of recent trauma, and a search should be made for a mass (or masses) in commonly involved mu scles. Aspiration of a suspicious mass may provide a rapid diagnosis, but incision with the patient under general anesthesia is required to drain larger abscesses. Both patients described in this report were also treated intravenously with a semisynthetic penicillin until clinical improvement was evident, at which time they were given oral antibiotic medication for two weeks. Dr. Gea Miller assisted in gathering information about Patient l. REFERENCES I.
Chacha PB: Muscle abscesses in children, in Urist MR. editor: Clinical orthopedics and related research, no 70, Philadelphia, 1970. JP Lippincott Company, Chapter 21, pp ' 174-180,
Marcus RT, and Foster WD: Observations on the clinical features, aetiology and geographical distribution of pyomyositis in east Africa, East Afr Med J 45: 167, 1968. 3. Traquair RN: Pyomyositis, 'J Trap Med Hyg 50:71, 1947. 4. Echeverria P, and Vaughn MC: "Tropical pyomyositis," Am J Dis Child 129:856, 1975. 5. Altrocchi PH: Spontaneous bacterial myositis, JAMA
2,
217:819, 1971. 6, Ashken MH, and Cotton RE: Tropical skeletal muscle abscesses (pyomyositis tropicans), Br J Surg 50:846, 1963. 7, Wheatley OM: Childhood accidents: prevention and treatment, Pediatr Ann 6:12. 1977.
8, Miyake H: Beitrage zur Kenntnis der sogenannten Myositis infectiosa, Mitt Grenzgeb Med Chir 13:155, 1904,
Severe hypertension in a patient with unilateral obstructive hydronephrosis and renal artery stenosis Matti Uharl, M.D.,· Mikko Remes, M .D., Peter Lanning, M.D., and Juhani Sepplinen, M.D ., 011111,
Finland
PERSISTENT, moderate, or severe hypertension in children is usually secondary in nature, and renal diseases are the most common causes.' In the series of Gill and
From the Departmentsof Pediatrics and Diagnostic Radiology, University of 01//1/, •Reprint address: Department oj Pedlatrtcs, University of 011111, 90210 Oulu 22, Finland.
coworkers,' obstructive uropathy and renovascular disorders were together the cause of 12% of all cases of hypertension in children. These diso rders can occur at the same time, but we have found only one report of hydronephrosis and renovascular disorders occurring independently but simultaneously.' We have recently treated a l2-year-old boy with renal artery stenosis and 0022-3476/78/0393-0458$00.20/0 e 1978 The C. V, Mosby Co.
Brief clinicaland laboratory observations
Volume 93 Number 3
simultaneous unilateral obstructive hydronephrosis due to pelvoureteral stenosis. CASE REPORT
A l2-year-old boy who had for months been having headaches and nausea was referred to the Department of Pediatrics, University of Oulu. The patients was of average size-height 154 em and weight 37 kg. A physical examination showed high blood pressure (210/140-170/120 mm Hg), but otherwise normal findings. There were no vascular changes in the fundi of the eyes. The abdomen was not auscultated. When measured previously in connection with an operation nine years earlier, the blood pressure had been normal. Abbreviation used IVP: intravenous pyelography Laboratory tests showed the blood pH to be 7.48; serum Na 145 mEq/l; K 3,2 mKq/l; creatinine 0.8 rng/dl. Peripheral renin activity (measured by using radioimmunoassay) was 10.3 ng/ ml/hr (normal values in this laboratory are 1.0 to 4.6 ng/ml/hr for this age), and the renin values in the vena cava and right and left renal veins were still higher-31.0, 58.0 and 25.9 ng/ml/hr, respectively. Peripheral renin activity was measured before antihypertensive medication, but the renal vein samples were taken while he was receiving medication. The ratio between the renal vein renin values was thus 2.2. Values for hemoglobin and vanillymandelic acid were normal. Because of the high blood pressure and symptoms, treatment with antihypertensive drugs was started immediately. During the first day, diazoxide was given, resulting in a drop in blood pressure to 1501105 mm Hg. The next day an electroencephalogram was performed, showing more low frequencies than normal; this abnormal finding has been seen in patients with hypertensive crisis. Intravenous pyelography demonstrated obstructive hydronephrosis in the right kidney due to .pelvoureteral stenosis, and renal arteriography disclosed a renal artery stenosis on the same side. The high blood pressure was subsequently treated with hydralazine and thiazide diuretics given orally. Because of the simultaneous hydronephrosis, renal artery stenosis, and hypertension, it was decided to perform nephrectomy; this was done two weeks after the initial diagnosis. The operative findings were the same as found by IVP and arteriography, namely hydronephrosis and renal artery stenosis.
DISCUSSION There are many causes of renal hypertension,' but hydronephrosis and renovascular disorders are not usual in children.' Bilateral or unilateral hydronephrosis can cause hypertension." • In all reports of unilateral obstructive hydronephrosis, renovascular disorders have not been excluded.' It seems likely that the hypertension in our patient was caused both by the renal artery stenosis and by the hydronephrosis." 6, 7 All children with unexplained severe hypertension should be examined by IVP. If in a patient with severe
459
hypertension a mild abnormality is found in the IYP, renal arteriography should be considered since an IVP does not always show all the conditions able to cause hypertension. According to our earlier experience, hypertension in children with unilateral hydronephrosis is not usually severe." Thus the severity of the hypertension in this patient gave rise to a suspicion of some other primary cause than unilateral hydronephrosis, Since renal hypertension is mediated mainly via the renin-angiotensin-aldosterone system, estimations of peripheral renin activity can give clues to possible renal origin.! Our patient had signs of secondary hyperaldosteronism, high renin activity, and a mild hypokalemic alkalosis. In unilateral renal diseases renin levels in the peripheral blood may be normal, but selective renin estimations from the renal veins show high renin values from the diseased kidney.' Renal vein ratios of 1.5: I or greater have been proposed as necessary before recommending surgery.' Godard" has shown, however, that in children the renin estimations probably do not have the same predictive value and that surgical treatment should be tried even in patients with negative results from the renin ratios. Similar results have been reported in adults. '0 The predictiveness of this ratio is difficult to estimate, and not clearly resolved. In our patient, the renal vein renin ratio w~s 2.2, and surgical treatment by nephrectomy was successful. REFERENCES I.
2.
3.
4.
5. 6.
7. 8. 9.
10.
Gill D, daCosta B, Cameron J, et al: Analysis of 100 children with severe and persistent hypertension, Arch Dis Child 51:951, 1976. Presto AJ, and Middleton RG: Cure of hypertension in a child with renal artery stenosis and hydronephrosis in a solitary kidney, J Urol 109:98, 1973. Loggie J, and Mcfinery P: Hypertension in childhood and adolescence, ill Rubin M, and Barrat T, editors: Pediatric nephrology, Baltimore, 1975, The Williams & Wilkins Company. pp 417-453. Weidmann P, Beretta-Piccoli C, Hirsch D, et al: Curable hypertension with unilateral hydronephrosis. Studies on the role of circulating renin, Ann Intern Med 87:437, 1977. Houston W: Hypertension due to hydronephrosis: Relief after nephrectomy, Br Med J 2:644, 1956. Goldblatt H, Lynch J, Hanzal RF, et al: Studies on experimental hypertension. The production of persistent elevation of systolic blood pressure by means of renal ischemia, J Exp Med 59:347, 1934. Miller S, and Lubahn J: Clinical features of renovascular hypertension in infancy, Pediatrics 56:108, 1975. Uhari M, and Koskimies 0: A survey of 164Finnish children and adolescents with hypertension (to be published). Godard C: Predictive value of renal-vein renin measurements in children with various forms of renal hypertension. An international study, Helv Pediatr Acta 32:49, 1977. Maxwell M, Marks L, Lupu A, et al.: Predictive value of renin determinations in renal artery stenosis, JAMA 238:2617, 1977.