Hypertension, Seizure, and Murmur in an 11-year-old Girl

Kyle Schmucker, MD* 2. Katherine B. Salciccioli, MD*,† 3. Thomas J. Seery, MD‡ 1. *Department of Pediatrics, 2. †Division of Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX 3. ‡Department of Pediatrics and Division of Cardiology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 1. Address correspondence to Kyle Schmucker, MD, Pediatric Emergency Medicine, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, AOB 2601, Pittsburgh, PA 15224. E-mail: schmuckerka{at}upmc.edu An 11-year-old girl presents to the emergency department for evaluation of acute on chronic headache and new onset vomiting. Physical examination reveals a weight of 53.2 kg (90th percentile), height of 155 cm (87th percentile), and a body mass index of 22.3 (90th percentile). She is afebrile with a heart rate of 113 beats/min, respiratory rate of 18 breaths/min, oxygen saturation of 100% on room air, and a blood pressure of 152/70 (>>99th percentile, stage 2 hypertension). The remainder of her physical examination is benign. Computed tomography (CT) scan imaging of the head is unremarkable. The hypertension and tachycardia are attributed to pain from the headache, and she is discharged from the emergency department with acetaminophen for the headache and primary care follow-up. Six days later, she returns to the emergency department with complaints of severe headache and vomiting, now with a blood pressure of 184/117 and heart rate of 98 beats/min. Her physical examination reveals a harsh early systolic ejection murmur loudest at the right upper sternal border radiating to the carotids. There is no gallop. She is well perfused without jugular venous distention or hepatomegaly. Her blood pressure remains markedly elevated despite doses of hydralazine, nifedipine, and amlodipine. A review of systems is positive for several weeks of headaches, an unintentional 10-pound weight loss, and recurrent elevated blood pressures at primary care visits. Ten weeks prior, she suffered a self-limited generalized tonic-clonic seizure at home. She returned to baseline prior to emergency medical services arrival in the home and was not transported for further evaluation. There is …