Hypertensive retinopathy as a masquerade neuroretinitis in a child: a case report

High blood pressure in children is rare and often underdiagnosed, but it can cause irreversible damage to target organs. Ocular signs of hypertensive retinopathy are nonspecific and may resemble those of neuroretinitis or papilledema, which can delay diagnosis.

A 9-year-old girl presenting with bilateral visual loss was referred to our emergency department. Best-corrected visual acuity was 20/200 in the right eye and counting fingers in the left. Fundus examination revealed bilateral optic disc swelling with a macular star and flame-shaped hemorrhages. Infectious work-up and neuroimaging were inconclusive. Reassessment showed severe hypertension (165/118 mmHg), hypokalemia, impaired renal and cardiac function. Plasma renin and aldosterone were markedly elevated. Imaging revealed a hypoplastic left kidney with subtotal renal artery stenosis and high-grade vesicoureteral reflux, contributing only 7% of total renal function on DMSA scintigraphy. Antihypertensive therapy with amlodipine, enalapril, and acebutolol normalized blood pressure, improved renal and cardiac function, and restored full visual acuity within six months. A left nephrectomy was subsequently performed to improve long-term blood pressure control.

This case demonstrates the importance of systematic blood pressure measurement in children with disc edema or neuroretinitis-like features. Severe hypertension should be considered early on. Pediatric guidelines recommend blood pressure targets below the 90th percentile with ACE inhibitors, angiotensin receptor blockers, calcium channel blockers, or thiazide diuretics as first-line agents. Nephrectomy may be indicated in cases of refractory hypertension when a hypoplastic kidney contributes less than 10% of overall function.