Clinician's Hypertensive Crises May Have an Occupational Link

The clinician experienced searing "hot poker" occipital headache, face flushing, neck rash, and an increase in BP
The clinician experienced searing "hot poker" occipital headache, face flushing, neck rash, and an increase in BP

Published in The Journal of Clinical Hypertension, this unusual case reports on a gastroenterologist who suffered repeated episodes of malignant hypertension brought on while he performed a medical procedure common to his practice.

The patient, a middle-aged gastroenterologist, presented to the hospital with orthostatic hypertension and an erythematous rash on his neck. His past medical history included well-controlled hypertension and impaired fasting glucose, however in the previous weeks he had been repeatedly hospitalized for hypertensive crises. During these episodes he would experience searing "hot poker" occipital headache, face flushing, and neck rash, and an increase in his blood pressure (BP) to >170/120mmHg; these episodes occurred while performing endoscopy and would resolve once the procedure was completed. Over a period of three weeks, the patient was hospitalized seven times with BP values sometimes reaching over 230/130mmHg. 

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Beyond his hypertension diagnosis, which had been managed with a single drug, no other significant medical history could explain these episodes. During observation in the hospital, it was noted that the patient's BP increased whenever he rotated his neck to the left, which he did during endoscopy as it was necessary for him to rotate and extend his neck to view the video monitors during the procedure. Comprehensive laboratory work-up as well as imaging did not provide any additional answers for the patient's condition. The patient was ultimately stabilized on amlodipine and labetolol, however he continued to have breakthrough episodes, which eventually led him to retire from his practice.

After extensive evaluation ruled out other etiologies, the authors speculate "that repetitive neck rotation and fixation positions while performing endoscopy led to baroreceptor failure in the gastroenterologist." Baroreflex failure is a rare condition that occurs "after damage to the carotid baroreceptors by neck trauma, surgery or radiation," however the cause may also be unknown.  As this occupational link has not been addressed in previous literature, the authors caution that clinicians performing endoscopy should be "mindful of workplace ergonomics." 

Reference:

1. Kram, Michael MD, Voaklander, Rebecca MD, Siegel H Jerome MD, Rph. Recurrent Hypertensive Crises in an Endoscopist: A Possible Occupational Link. The Journal of Clinical Hypertension. DOI: 10.1111/JCH.12842.

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