P0646 - High Blood Pressure: A PRES-ing Matter Even in Children

This is a case of a 4 year-old boy with no significant past medical history initially presenting to an outside hospital with new-onset seizures. Upon arrival, his blood pressure was 160/110 mmHg with heart rate of 150. He received a 300 mL fluid bolus prior to transfer to our hospital for neurological evaluation. Upon presentation to our emergency department (ED), patient received an additional 300-mL fluid bolus without repeating blood pressure. Patient was noted to be “appropriately irritable” and not following commands on initial assessment. He later spiked fever in the ED, and subsequently underwent lumbar puncture to rule out meningoencephalitis. Patient was admitted to pediatric floor for seizure work-up and empiric treatment of meningoencephalitis. On day 2 of admission, MRI brain was completed, which revealed abnormal patchy T2/FLAIR signal involving left frontal, parietal, and occipital lobes, as well as bilateral cerebellar hemispheres. The appearance resembled vasogenic edema and likely represented posterior reversible encephalopathy syndrome (PRES). Patient’s blood pressure was retrospectively reviewed and found to be persistently elevated since admission. He was consequently transferred to pediatric intensive care unit for management of hypertensive emergency. He was given intravenous diuretic and started on nitroprusside drip. His blood pressure was effectively reduced and maintained at appropriate range even after transition to oral antihypertensive agents.

This case highlights the importance of not only monitoring, but also interpreting, blood pressures in pediatric patients. Because hypertension is much less prevalent in our pediatric population than in our adult patients, we are often less attentive to the blood pressure as a vital sign. The patient received multiple fluid boluses (from different facilities) despite his elevated blood pressure, which suggests that although the blood pressure was being checked, it was overlooked. More importantly, he continued to have elevated blood pressures (systolic ranging from 140 mmHg to 170 mmHg) for the next 2 days without any intervention. While blood pressure is arguably one of the most tale-telling vital signs and often the first one to be looked at when managing adult patients, it is too often overlooked in the pediatric population. Ultimately, in this patient’s case, failure to address the blood pressure led to delay in diagnosis of PRES. It is also interesting to note that although hypertensive encephalopathy and reversible posterior leukoencephalopathy syndrome (RPLS) are frequently high on the list of differential diagnoses for adult patients with delirium, these are not diagnoses that first come to mind in pediatric acute encephalopathy. Raising awareness of hypertensive encephalopathy and RPLS as potential diagnoses in pediatric patients with new-onset seizures can result in timely and appropriate treatment, and ultimately improve outcomes.