Intussusception Presenting with Malignant Hypertension and Lethargy
A 10-month-old boy with a body weight of 9.6 kg presented with progressive lethargy. His past medical history was unremarkable. He had suffered from gastritis 2 weeks before and started vomiting again 2 days before admission. The patient had no fever, excessive sweating or diarrhea, and his urine output was normal. Physical examination revealed a sleepy but easily arousable infant with a heart rate of 160 per minute, a respiration rate of 32 per minute and a body temperature of 37.7°C. On all four extremities, a blood pressure of 135/95 mm Hg was measured, a value above the 99th percentile (P) by age and height (e.g. P 95th is 103/56 mm Hg). There were no signs of meningitis or intracranial hypertension, no abnormalities in sensibility and strength, and reflexes were normal. Cardiopulmonary examination revealed no heart murmurs, and breath sounds were normal. The abdomen was not painful to palpation and there were no masses. No edema was found, and the skin was unremarkable. Based on the combination of hypertensive crisis and the neurological findings, the diagnosis of malignant hypertension was made and the patient was admitted to our pediatric intensive care unit for evaluation and intravenous antihypertensive therapy [, , ]. Nicardipine at 1 mcg/kg/min lowered his blood pressure to an acceptable level of 105/55 mm Hg (P 95th) within a few hours.\nLaboratory results showed a normal complete blood cell count, serum electrolytes (Na 137 mmol/l, K 4.1 mmol/l, Cl 104 mmol/l), creatinine 13 µmol/l, urea 3.6 mmol/l and glucose 5.6 mmol/l. Glomerular filtration rate was 118 ml/min, and blood lactate as well as ammonia levels were normal. An arterial blood gas analysis revealed a mild meta-bolic acidosis with respiratory compensation (pH 7.40, bicarbonate 17.7 mmol/l, pCO2 29 mm Hg).\nA computed tomography of the brain revealed no intracranial bleeding, no tumor and no signs of elevated intracranial pressure. An abdominal ultrasound showed normal kidneys without hydronephrosis, and Doppler studies were unremarkable. On the ultrasound, an abdominal mass with the characteristic ‘target sign’ of an ileocecal intussusception was visualized in the right lower quadrant (fig. ). Radiographically guided hydrostatic reduction with water-soluble contrast failed. Laparotomy was performed, which confirmed the diagnosis of intussusception. After repositioning, intestinal perfusion was adequate and bowel resection was not necessary. The anesthetics used during the surgery had no major influence on the blood pressure. Following surgery, the mental status returned to normal and antihypertensive medication could be discontinued. His blood pressure decreased to a normal level (P 50th 90/40 mm Hg).