He has a history of recurrent UTIs and was diagnosed with grade III bilateral VUR at age 2 years. He has flank tenderness, complains of headache, and has photosensitivity in the bright room. His mother notes that he appears to have sunken eyes. Vital signs are temperature 39.5°C (103.1°F), heart rate 125 bpm, respirations 35 breaths per minute, and blood pressure 143/90 mm Hg. Labs show WBCs 13 × 103/μL, hemoglobin 9.5 g/dL, platelets 235 × 103/μL. Na 146 mEq/L, K 5.4 mEq/L, Cl 108 mEq/L, CO2 13 mEq/L, BUN 25 mg/dL, and creatinine 1.5 mg/dL. You notice his baseline creatinine from 6 months ago was 0.8 mg/dL. While collecting urine for culture 400 mL of urine was drained.
What is the most likely explanation for this hypertensive emergency?
A. Acute abdominal pain that warrants surgical evaluation.
B. Acute kidney injury with intravascular volume overload.
C. Acute pyelonephritis with reflux nephropathy.
The correct answer is “C.” Acute pain can be associated with elevated blood pressure readings but is not typically associated with signs of end organ involvement with headache and photosensitivity. Intravascular volume overload in the context of acute kidney injury with creatinine of 1.5 mg/dL is an appropriate consideration. However, the patient has sunken eyes and there is no evidence of oligoanuria. His longstanding history of VUR in the context of myelomeningocele and appendicovesicostomy is consistent with an underlying neurogenic bladder. Therefore, reflux nephropathy with acute pyelonephritis is the most likely explanation. Longstanding reflux nephropathy can lead to chronic kidney disease and end-stage renal disease. Pheochromocytoma can manifest as an acute hypertensive crisis. However, it is unlikely to present with acute rise in serum creatinine.