Headache and Hypertension in a 9-year-old Girl

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...