Headache and Hypertension in a 9-year-old Girl

Jacob Adney, MD* 2. Seth Koehler, DO† 3. Lewis Tian, MD‡ 4. Joseph Maliakkal, MD§ 1. *Department of Pediatrics, St Louis Children’s Hospital, Washington University School of Medicine, Saint Louis, MO 2. †Southeast Primary Care, SoutheastHEALTH, Jackson, MO 3. ‡Department of Psychiatry, Saint Louis University Hospital, Saint Louis University School of Medicine, St Louis, MO 4. §Department of Pediatrics, Division of Pediatric Nephrology, Cardinal Glennon Children’s Hospital, Saint Louis University School of Medicine, Saint Louis, MO A 9-year-old girl presents to her pediatrician with a headache that began on the day of presentation. Blood pressure (BP) is measured at 208/140 mm Hg using an oscillometric technique with an automatic BP cuff in the right upper extremity while the patient was calm. Body mass index was 21.72 (95th percentile for age). Medical history includes an episode of flank pain that began 7 days earlier. This was diagnosed as a presumed urinary tract infection, treated with oral cefdinir, and resolved 4 days before presentation. Urine culture is negative. Her hypertension is treated with 2 intravenous doses of hydralazine (0.25 mg/kg), but her BP remains elevated and her headache persists. She is given 1 intravenous dose of labetalol (0.25 mg/kg) and is transferred to a local tertiary pediatric emergency center. Physical examination confirms an elevated BP measurement of 143/102 mm Hg. No hyperpigmentation, nevus flammeus (port-wine stains), or hemangiomas are found on skin examination. Fundoscopic examination shows no arterial narrowing, hemorrhages, exudates, or papilledema. Laboratory evaluation demonstrates venous pH 7.3, a serum potassium level of 6.7 mEq/L (6.7 mmol/L), and a serum carbon dioxide level of 18 mEq/L (18 mmol/L). Initial metabolic profile otherwise shows a serum sodium level of 134 mEq/L (134 mmol/L), a serum chloride level of 113 mEq/L (113 mmol/L), and a serum calcium level of 9.07 mg/dL (2.27 mmol/L); serum phosphorus, blood urea nitrogen, creatinine, albumin, and serum glucose levels are normal. Urinalysis shows urine pH 7 (expected to be <5.5 in the setting of acidosis). She is admitted to the hospital for further evaluation and management. Given the patient’s severe hypertension, our differential diagnosis includes renal disease, cardiac anomalies, endocrinopathy, and medication-induced secondary hypertension. Renal ultrasonography shows normal kidneys with no structural abnormalities, and renal function tests are within normal limits. Echocardiography reveals concentric …