A 15-year-old girl presented to the ophthalmology department with complaints of headache and intermittent blurring of vision in both eyes for 1 month. She had intermittent fever at night associated with pain in the lower abdomen and significant weight loss for the past 2 months. On ocular examination, the best-corrected visual acuity was 20/20 and N-6 in both eyes. Color vision measured using Ishihara's chart was normal bilaterally. Anterior segment examination including pupillary reaction was normal bilaterally. Dilated fundoscopy revealed bilateral optic disc edema, with splinter hemorrhage near the optic disc in the left eye [Figure 1a and b]. Perimetry (Humphrey Field Analyzer, SITA 30-2) showed an enlarged blind spot in both eyes. General examination revealed facial puffiness associated with pedal edema and tenderness on flanks. Her blood pressure was 220/110 mmHg. We referred the patient to the nephrology department.
Urine microscopy showed leukocyturia and proteinuria. Blood urea and serum creatinine levels were elevated. Salient laboratory investigations have been highlighted in Table 1. Bilaterally enlarged kidneys (right kidney -9.6 cm x 3.7 cm and left kidney -10.3 cm x 3.9 cm) were detected on the ultrasound abdomen. In view of bilateral swollen kidneys, obstructive pathology was reviewed but there was no upper tract stenosis. Hence, cystoscopy was planned which showed a partially duplicated pelvicalyceal system. Urine sample from the upper urinary tract was sent for culture and acid-fast bacilli (AFB) stain. CBNAAT was negative and urine bacterial culture showed no growth. As there was persistent subnephrotic proteinuria with active sediments, renal biopsy was done which was suggestive of epithelioid cell granuloma along with Langhans type of giant cell and caseous necrosis [Figure 2]. Chest radiography was normal. The Mantoux test was negative (an induration of 3 mm). In view of persistent papilledema in both eyes, neurology consultation was also done. Magnetic resonance imaging and magnetic resonance venography were normal. Cerebrospinal fluid opening pressure was normal (11 cmHg).
Based on these clinical and laboratory findings, we diagnosed it as a case of refractory hypertension due to interstitial nephritis (TB) with bilateral Grade IV hypertensive retinopathy. The patient was started on antitubercular treatment (four-drug regimen) in the intensive phase along with antihypertensive medication (calcium channel blocker, angiotensin-converting enzyme inhibitor, and beta-blocker) and appropriate systemic antibiotic. After 2 months, there was a complete resolution of disc edema [Figure 3a and b]. At 6 months, the patient was stable and on a single antihypertensive medication. Her renal parameters are normal (blood urea - 27 mg/dl and serum creatinine - 1.87 mg/dl) and she is constantly following up with the nephrologist. She can perform her daily activities well without any physical and psychological disturbances.