An unusual cause of headache and HTN in a pediatric patient
Published in the American Journal of Medicine, the authors report a case of a 14-year-old girl who presented with headache and hypertension. She responded poorly to medical treatment and subsequently developed anxiety and difficulties with concentration. Three months later, she visited ophthalmology department because of blurred vision. Ophthalmic evaluation revealed bilateral Kayser-Fleischer rings. Finally, she was diagnosed with Wilson disease.

A previously healthy 14-year-old girl was referred because of headache for 3 weeks. Prior evaluation in a rural hospital revealed that she had hypertension; however, computed tomography revealed no intracranial lesions. At ED, she had a temperature of 36.5°C, heart rate of 74 beats per minute, respiratory rate of 18 breaths per minute, and blood pressure of 167/127 mm Hg. The initial neurologic evaluation, including all cranial nerves, deep tendon reflexes, and sensation, was normal.

She was discharged and took amlodipine 5 mg once daily; however, she continued to experience headache, and her blood pressure control was poor. She subsequently developed anxiety and difficulties with concentration. Brain magnetic resonance imaging was normal.

Three months later, she visited ophthalmology department because of blurred vision. Ophthalmology evaluation revealed bilateral Kayser-Fleischer (KF) rings. The blood chemistry values, including liver function, were within normal limits. The urinary copper excretion was elevated, at 68.8 μmol per 24 hours, and the ceruloplasmin level was less than 8.45 μg/dL (reference range, 20-40 μg/dL). Chelation treatment with 250 mg trientine twice daily was initiated.

A diagnosis of Wilson disease (WD) was made and confirmed by genetic testing of gene ATP7B defects. She reported resolution of headache and hypertension after chelation treatment.

Learning Points:-

- This case emphasizes that children with headache and hypertension merit aggressive evaluation and management.

- In the present case, 3 months after the first ED visit, the patient presented with KF rings and neurologic/psychologic problems; thus, the WD diagnosis was fairly obvious.

- However, at her first visit to our ED, her only symptom was headache, a rare neurologic symptom of WD, and her blood chemistry values, including liver function, were within normal limits, making a correct diagnosis very difficult.

- Children with headache and hypertension merit aggressive evaluation and management.

Read in detail about the case here: https://www.ajemjournal.com/article/S0735-6757(12)00214-8/fulltext
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Dr. A●●●u K●r Ophthalmology
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