Visual diagnosis: a child who has a nosebleed and high blood pressure.

Abstract

1. Andrea Herman, MD* 1. 2. *Doernbecher Children’s Hospital, Oregon Health Sciences University, Portland, OR. An 11-year-old boy is admitted to the pediatric intensive care unit because of high blood pressure. Eight hours earlier, he suddenly developed intermittent nosebleeding. His parents brought him to the emergency department because they could not stop the bleeding over the previous hour. On arrival, the patient’s blood pressure was 250/170 mm Hg. He denied headache, dizziness, or blurred vision. The nosebleed was stabilized with pressure and packing. Because his blood pressure improved minimally after three separate administrations of intravenous labetolol, he was transferred to the intensive care unit for further evaluation and therapy. The patient’s medical history revealed a 6-month history of episodic headaches, vomiting, and fatigue. Three months ago, these episodes occurred weekly, prompting the patient to seek medical care. Findings on physical examination were normal, including a systolic blood pressure of 95 mm Hg. Results of laboratory evaluation, consisting of complete blood cell count, urinalysis, serum glucose, thyroid stimulating hormone, and computed tomography (CT) of the head (Fig. 1⇓ ), were normal. Migraine headaches were diagnosed, and the patient was treated with propranolol. After 2 weeks without symptomatic improvement, the boy’s parents discontinued propranolol therapy. Figure 1. Normal CT scan of the head. Two weeks later, the patient developed blurred vision, returned to the hospital, and was admitted for evaluation. His systolic blood pressures ranged from 115 to 164 mm Hg and diastolic blood pressures from 75 to 103 mm Hg. An ophthalmologist noted decreased vision in the right eye as well as papilledema and stellate macular changes on retinal examination. Magnetic resonance imaging (MRI) of the head demonstrated patchy high-signal changes in the white matter (Fig. 2⇓ ). Cerebrospinal fluid evaluation revealed an opening pressure of 27 mm H2O, a white blood cell count of 2 cells/mcL, a red blood cell count of 7 …