What is the appropriate management and diagnosis for a 25-year-old male with no known history of hypertension, presenting with acute onset fever, headache, vomiting, and significantly elevated blood pressure (hypertension), following alcohol consumption 3 days prior, and currently on amlodipine (calcium channel blocker) 5 mg OD, paracetamol (acetaminophen), domperidone (antiemetic), doxycycline (antibiotic), and metoclopramide (antiemetic)?

Management of Acute Hypertension in a Young Patient with Fever and Neurological Symptoms

Most Likely Differential Diagnoses

This clinical presentation most likely represents either acute febrile illness with secondary hypertension OR early hypertensive emergency with possible encephalopathy, rather than primary essential hypertension. 1, 2

The key differential diagnoses include:

• Acute infection-related hypertension – The combination of fever, headache, and vomiting with BP elevation 160/100 mmHg suggests stress-induced hypertension from acute illness, particularly given the temporal relationship with symptom onset 1, 3
• Early hypertensive encephalopathy – While BP is not severely elevated (not >180/120 mmHg), the neurological symptoms (headache, vomiting) warrant careful monitoring for progression 1, 2
• Meningitis/encephalitis – Fever, headache, and vomiting are classic symptoms; doxycycline suggests consideration of tick-borne illness 1
• Alcohol withdrawal – History of alcohol consumption 3 days prior could indicate early withdrawal, which can cause hypertension and autonomic symptoms 4
• Secondary hypertension – In a 25-year-old, consider pheochromocytoma, renal disease, or drug-induced causes 4, 1

Stress/Illness-Related vs. True Hypertension

This is most likely stress/illness-related hypertension rather than true essential hypertension. 1, 3

Key supporting evidence:

• Age and timing – A 25-year-old with no prior hypertension history presenting with acute BP elevation concurrent with acute illness strongly suggests reactive hypertension 3
• BP threshold – At 160/100 mmHg, this does NOT meet criteria for hypertensive emergency (>180/120 mmHg with organ damage) 4, 1
• No target organ damage documented – Absence of focal neurological deficits, altered sensorium, or documented end-organ injury suggests hypertensive urgency at most 4, 1
• Natural history – Up to one-third of patients with elevated BP in acute illness normalize without intervention once the underlying condition is treated 3

Appropriateness of Amlodipine vs. Observation

Amlodipine should be discontinued and BP should be observed without antihypertensives initially while treating the underlying acute illness. 1, 3

Rationale for stopping amlodipine:

• No indication for immediate treatment – BP 160/100 mmHg without acute target organ damage does NOT constitute a hypertensive emergency requiring immediate pharmacological intervention 4, 1
• Risk of harm – Aggressive BP lowering in the setting of acute illness may precipitate cerebral, renal, or coronary ischemia, particularly if the patient becomes volume depleted from fever and vomiting 4, 1
• Oral agents inappropriate for true emergencies – If this were a genuine hypertensive emergency, parenteral IV therapy would be required, not oral amlodipine 4, 1
• Treat the underlying cause first – Many patients with acute pain, fever, or distress have transiently elevated BP that normalizes when the underlying condition is treated 1, 3

Common pitfall to avoid: Do not treat asymptomatic or mildly symptomatic BP elevation in the acute care setting without evidence of target organ damage, as this may cause more harm than benefit 1, 3

Recommended Management Pathway Based on Investigation Outcomes

Immediate Actions (First 24-48 Hours)

• Discontinue amlodipine and observe BP while treating acute illness 1, 3
• Continue symptomatic treatment – Paracetamol for fever is appropriate 5
• Monitor for metoclopramide complications – Given one dose of injectable metoclopramide, watch for extrapyramidal symptoms (acute dystonic reactions occur in 1 in 500 patients, more common in patients <30 years old) 5
• Complete the advised investigations – CBC, RFT, LFT, FBS, PPBS are appropriate baseline tests 1, 2

Based on Investigation Results:

If investigations show evidence of target organ damage:

• Renal injury (elevated creatinine, proteinuria, abnormal urine sediment) – Consider true hypertensive emergency; admit to ICU for IV labetalol or nicardipine targeting MAP reduction of 20-25% over several hours 4, 1, 2
• Thrombotic microangiopathy (thrombocytopenia, elevated LDH, decreased haptoglobin) – This indicates malignant hypertension requiring immediate ICU admission and parenteral therapy 4, 1, 2
• Cardiac injury (if troponins were checked and elevated) – Indicates acute coronary syndrome requiring immediate intervention 4, 1

If investigations are normal or show only acute infection:

• Continue treating the underlying infection with doxycycline as prescribed 1
• Recheck BP after 24-48 hours once fever and acute symptoms resolve 3
• If BP normalizes – No antihypertensive therapy needed; arrange outpatient follow-up in 2-4 weeks to confirm normalization 3
• If BP remains elevated (≥140/90 mmHg) after acute illness resolves – Initiate oral antihypertensive therapy with ACE inhibitor or ARB plus calcium channel blocker, with outpatient follow-up 1

Long-term Follow-up (If Hypertension Persists)

• Screen for secondary hypertension – In a 25-year-old, 20-40% of malignant hypertension cases have secondary causes including renal artery stenosis, pheochromocytoma, or primary aldosteronism 4, 1, 2
• Target BP <130/80 mmHg within 3 months if true hypertension is confirmed 1

Red-Flag Features Mandating Urgent Neuroimaging or Referral

Immediate ICU admission and neuroimaging (CT/MRI brain) are required if ANY of the following develop: 4, 1, 2

Neurological Red Flags:

• Altered mental status – Lethargy, confusion, somnolence, or decreased level of consciousness indicating possible hypertensive encephalopathy 4, 1, 2
• Seizures – New-onset seizures suggest hypertensive encephalopathy or intracranial hemorrhage 4, 1, 2
• Focal neurological deficits – Weakness, numbness, speech difficulties, or visual field defects indicating possible stroke 4, 1, 2
• Severe persistent headache with visual disturbances (beyond current symptoms) – Especially if accompanied by papilledema on fundoscopy 4, 2
• Cortical blindness – Sudden vision loss indicating posterior reversible encephalopathy syndrome (PRES) 1, 2

Cardiovascular Red Flags:

• Chest pain – Suggests acute coronary syndrome or aortic dissection 4, 1
• Acute dyspnea with pulmonary edema – Indicates acute left ventricular failure requiring immediate intervention 4, 1
• BP escalation to >180/120 mmHg – Crosses threshold for potential hypertensive emergency 4, 1

Other Critical Signs:

• Oliguria or signs of acute kidney injury – Suggests hypertensive nephropathy or thrombotic microangiopathy 4, 1, 2
• Advanced retinopathy on fundoscopy – Bilateral retinal hemorrhages, cotton wool spots, or papilledema indicate malignant hypertension 4, 1, 2
• Hemolysis with thrombocytopenia – Indicates hypertensive thrombotic microangiopathy requiring immediate intervention 4, 1

Specific Monitoring Parameters:

• Serial BP measurements – If BP rises to >180/120 mmHg, reassess immediately for target organ damage 4, 1
• Neurological checks every 4-6 hours – Watch for development of altered consciousness, visual changes, or focal deficits 1, 2
• Fundoscopic examination – Essential to detect malignant hypertensive retinopathy 4, 2

Critical pitfall to avoid: Do not dismiss "normal" BP readings if they occur intermittently—patients with hypertensive emergencies may have fluctuating BP, and the history of prior severe elevations is significant 1