5.13 A Peculiar Case of Secondary Hypertension
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High Blood Press Cardiovasc Prev 2007; 14 (3): 145-196 1120-9879/07/0003-0145/$44.95/0 © 2007 Adis Data Information BV. All rights reserved.
Hormonal Mechanisms 5.13 A Peculiar Case of Secondary Hypertension E. Porteri,1 D. Rizzoni,1 F. Zani,1 C. Platto,1 N. Rizzardi,1 A. Rosati,2 R. Rao,2 A. Miozzo,2 V. Vergani,2 A. Padovani,2 E. Agabiti Rosei1 (1) Clinica Medica, Department of Medical and Surgical Sciences, University of Brescia, Br Brescia; (2) Chair of Neurology, University of Brescia, Brescia, It Italy Introduction: Secondary hypertension sometimes represents a hard diagnostic and therapeutic challenge. Recently, we could observe a very peculiar clinical case. Methods: A young man (37 years) was admitted to our medical department, for the occurrence of headache and elevated blood pressure values. The patient was recently discharged from a neurology department for acute meningoencephalitis with clear liquor. At admission, blood pressure values were 210/125 mm Hg, with tachycardia (120 bpm), while on therapy with amlodipine and doxazosine. After a couple of days, the patient developed seizure with aphasia. Twenty-four hour blood pressure monitoring confirmed the presence of elevated blood pressure values, with a further, sudden increase during seizure and an abrupt fall 2-3 hours after the epileptic attack. The patient was then admitted again to the neurology department, and therapy with doxazosine (up to 4 mg 3 times a day) and carvedilol (up to 12.5 mg two times a day) was up-titrated until satisfactory blood pressure control was achieved. In the same time, proper antiepileptic treatment was administered (diazepam, carbamazepine). A slow improvement of neurological conditions occurred in the following days, Hormonal assays demonstrated: 1) urinary excretion of noradrenaline and adrenaline below normal upper limits, even during fits; 2) urinary excretion of 5 hydroxy-indolacetic acid (serotonin metabolite) within normal limits the day before fits, markedly increased (4 times) during fits (32.5 mg/24 hours), and again within normal limits in the following days. In the following days, antihypertensive treatment was down-titrated, in parallel with the improvement of neurological conditions Results: After 2 weeks from discharge the patient was admitted to our outpatient clinic. Blood pressure values were 135/95 mm Hg, with symptoms and signs of hypotension in the evening hours. Antihypertensive treatment was further down-titrated (doxazosine 2 mg twice a day, carvedilol 6.25 mg twice a day). Conclusions: In the course of neurological diseases, pronounced and sudden increases in blood pressure values may occur. It was previously suggested that, during seizure, an elevated incretion of serotonin may be present (Bagdy G, J Neurochem 2007, 100: 857-873). Therefore, in addition to commonly recognised forms of secondary hypertension, diseases of the central nervous system should be taken into account in the presence of sudden increase in blood pressure values.
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