This case discusses a 16-year-old male who presented with worsening headache, abdominal pain, and elevated blood pressure. He had a history of headaches for over a year since a motor vehicle accident, which had been treated unsuccessfully. On admission, he was hypertensive to dangerous levels and found to have leukocytosis, lactic acidosis, elevated troponin, and renal failure. Further evaluation revealed inguinal hyperpigmentation and right upper quadrant tenderness.

1. ClinicoPathologicalCasediscussion
Presenter : Dr Jason Dsouza
Selector: Dr Lea Varghese
Moderator: Dr Habib Khan

2. ChiefComplaints
16 year old , Male:
Headache since 1 year 5 months
Abdominal pain since 1 day
Elevated Blood pressure recordings since 1 day

3. Howdiditallbegin?
 Child was apparently normal until 17 months prior to
current admission
At 14years 7months of age
History of Road traffic accident
 Complaints of Episodic headache and neck pain
multiple episodes per week

4. 2months
later…..
 Trauma while playing soccer (Collided with other
person)
 Worsening of Neck pain and headache with Pain
severity score – 8/10
 On examination : Normal vitals, mild tenderness in
trapezius
 X-ray cervical spine - Normal

5. FORTHENext15
months:
 On regular follow-up with Pediatrics and Neurology
dept’s
 Received multiple medications for headache (Ibuprofen,
Nortryptyline, Sumatriptan, Cyclobenzaprine &
Diazepam) –No Improvement of symptoms
 Tried alternative therapy with Acupuncture, Physical
therapy, Chiropractic, Massage therapy

6. 3monthspriorto
currentadmission
At 15 year 9months of age
 Nausea with episodes of headache; Headache
worsened on lying down and on physical activity
resulting in Vomiting and Tunnel vision
 Intensity of pain reduced after vomiting
 O/E: Tachycardia(104/min)
BP: 128/80mmHg(50-90th centile)
 Stopped outdoor sports on Medical advice

7. 2dayspriorto
current
admission:
(17monthsafteronset)
 Worsened headache awoke patient from sleep;
 Nausea was constant with 2 episodes of vomiting /day.
 Unable to attend school due to symptoms.
 O/E: Tachycardia (HR:115/min) with other vitals normal
BP:120/64mmHg  (50-90th centile)
General physical examination :Normal ;
BMI : 27Kg/m2  OVERWEIGHT

8. Chronology:
 17 months back  ACUTE ONSET HEADACHE
precipitated by Trauma
 15 months later EPISODIC HEADACHE persisting
despite various treatment
 2 months later  HEADACHE with NAUSEA,
VOMITING and TUNNEL VISION (?Signs of raised
ICT/ ?Aura)

9. Diagnosedas….
Mixed migraine and Tension Type
Headache
Discharged with Prednisolone(Not taken), Zlometriptan &
Ondansetron

10. HEADACHE
 TYPES:
 PRIMARY HEADACHE: TTH, Migraine, TAC
 SECONDARY HEADACHE: Infection (intracranial &
extracranial), tumor, Intracranial hemorrhage, Vascular
disorder, Post Traumatic headache

11. 4patterns of
headache
 Acute: Single episode of pain without history of such episode
 Acute Recurrent: Recurrent attacks of pain separated by symptom
free intervals
 Chronic Progressive: Gradual increase in frequency and severity
of headache
 Chronic non progressive or Chronic Daily: Frequent/constant
Headache (> 4months h/o > 15 headaches/mo, with headache
lasting > 4 hr)

12. CATEGORY COMMON CAUSES LESS COMMON RARE CAUSES
INTRACRANIAL -Infections: Meningitis,
Meningoencephalitis,
Brain Abscess.
-Vascular causes:
Migraine
Tumors
Head Trauma
Hemorrhage
(Hypertension, AV
malformations)
Pseudotumor Cerebri
EXTRACRANIAL -Tension Headache
-Systemic Infections: Eg:
Malaria
-Viral Infections Eg:
Varicella
-Localized Infections:
Eg: Sinusitis, dental
abscess, Mastoiditis
Hypertension Refractive errors
Causes of Headache

13. Approach to
Headache

14. Headache
Recent onset/first
episode
Associated Features
Eg: Fever,URI,Trauma
Next slide
No associated
features
Analgesics and
Observe
Recurrences
present (Be alert
for Red Flag
signs)
Long
standing(weeks
to months )
Recurrent
Elicit Criteria for
migraine
MIGRAINE
Near Continuous
-Sinusitis
-Alert for Red flag
signs
-Record Blood
pressures
-Refractory error
IMAGING SOS

15. Investigate source of infection; be vigilant for intracranial infective focus
Fever, Abnormal neurological evaluation
YES NO
TTH, Cluster
Headache,
Substance abuse,
Hypoxia,
Hypercarbia,
hypertension crisis
Altered mental status & Meningeal signs
Meningitis, SAH
Vasculitis
Encephalitis
Encephalitis,
Viral / Bacterial Illness
Meningismus
Abscess(Tonsillar/Retropharyngeal)
Sinusitis
Dental Abscess
Other Infection (ENT/Cranial)
NO
YES
PERFORM LP
Abnormal Normal

16. RedFlagsignsofheadache
a) Short history (‘First’ or ‘worst’) or recent recurrent severe headache for few
weeks
b) Accelerated course, change in character over weeks or days
c) Headache suggesting raised ICT (Early morning headache, vomiting in morning,
pain disturbing sleep, headache worse with cough or Valsalva)
Continued……

17. RedFlagsignsofheadache
d) Associated symptoms of personality changes, weakness, visual disturbances, confusion, focal
weakness, seizures or fever
e) Underlying history of neurocutaneous syndrome, history of systemic illnesses (eg. known
malignancy with possible metastases, hypercoagulopathy)
f) Young age of child (< 3 years old)

18. Tensiontype
Headache
 15% of older children, 8-12 years of age (most frequent)
 Typical pattern is that patients awaken feeling well, with throbbing
pain beginning gradually and escalating throughout the day;
Relieved on rest
 TTH are classified as either episodic or chronic.
 Normal neurologic and physical findings, except for possible scalp
tenderness; Sleep disturbances, school absence and chronic
analgesic use are common.

19. Migraine
 Migraine with/without aura:
Periodic episodes of headache
Pulsating quality
Photophobia
Phonophobia
Nausea, vomiting
Relieved by sleep
Family history present
 Compared to Adults: Shorter duration (1-48hours), bilateral(bifrontal)

20. IntracranialSpace
occupyinglesion
 Second most common cause of childhood malignancy
 Mechanism: Obstruction to CSF flow (Hydrocephalus)/ Direct Traction on
vascular or Dural structures
 Symptoms: Late night / early morning headache (Progressive)
Vomiting (Projectile)
Poor academic performance
Weakness
Visual disturbances
Personality / Behavioural changes
Papilledema
Ataxia/ Movement disorders
 Physical examination abnormal findings, Papilledema & neurologic deficits

21. SUPRATENTORIAL INFRATENTORIAL
Behavioral changes Presents with signs of raised ICT :
Vomiting, headache, Tunnel vision
Focal seizures/deficits Imbalance /Swaying
Poor scholastic performance Hydrocephalus due to obstruction to
flow of CSF

22. Ourcurrent
diagnosis
Mixed Migraine Disorder
?Signs of raised ICT
?Aura

23. Ondayof
admission:
 Sudden onset Pain abdomen, on right side, Severe in
nature; Awoke the patient from sleep
 Headache, Nausea and Neck pain was constant
 O/E(@ ED) : Tachycardia (160/min)
BP-239/162mmHg (>99thcentile)
SpO2: 100% via nasal prongs at 4 L/min
RR: 18/min

24. INVESTIGATIONS
 ECG: Sinus tachycardia with increased R and S wave
amplitudes
One hour later
 Repeat ECG: Ectopic atrial Rhythm, with frequent
premature ventricular contractions(HR:66/min)

25. Labinvestigation:
Leucocytosis (WBC:22,380cells/dl),
Lactic acid: 24mg/dl (Normal:5-20mg/dl)
Creatinine: 1.3mg/dl (Normal:0.6-1.3mg/dl)
 USG abdomen & ECHO: No information

26. Management:
 Started on IV hydromorphone(opiod), Morphine, ondansetron,
metoclopramide and Lactated Ringers lactate
 Nitroglycerin infusion started SBP decreased to 143mmHg
Infusion stopped SBP increased to 212mmHg
 IV Labetalol infusion started SBP decreased to 92mmHg
 Esmolol infusion started and was transferred to current hospital PICU
for further care.
 Esmolol infusion stopped (within 3 hours of presentation to current
hospital)

27. Drugs Nitroglycerine Sodium Nitroprusside
Mechanism of action Powerful venodilator, mild arteriolar
and coronary vasodilator
Short acting vasodilator effect
on Venous and arteriolar ends
Indication Post Cardiac surgeries Systemic hypertension , Low
cardiac output state, acute
heart failure, post cardiac
surgeries
Side effects Hypotension, Tachycardia,
Methemoglobinemia
Hypotension, increased ICP,
Headache, Dizziness,
Sweating and Palpitations; do
not combine with ACEi ,
Vasodilators, Beta blockers
Contraindications Hypotension, hypoxia, Hypertrophic
cardiomyopathy
Renal /hepatic impairment

28. Approachto
Hypertension
 Prevalence is 2-5% in India
 Two types: Primary or Secondary Hypertension
 Primary more common than secondary; causes attributed to
obesity, change in dietary habits , decreased physical activity and
increased stress
 Normal Blood Pressure : <90th centile for age, gender and height
 Pre Hypertension: 90-95th centile for age, gender and height
 Hypertension: > 95th centile on 3 separate occasions

29. Screening for
hypertension
 At least once a year for > 3years old children
 At risk individuals: History of prematurity, VLBW children,
interventions in NICU, Congenital heart disease , recurrent
UTI, Known Renal and Urological Disease, Hematuria and
proteinuria.
 Family history of Congenital renal disorders
 Malignancy
 Conditions associated with HTN: NF, Tuberous sclerosis and
Ambiguous genitalia

30. Causes
Renal : Parenchymal(Chronic GN, ADPKD, Renal Dysplasia,
Obstructive uropathy) or Renovascular(Takayasu,RAS,Renal artery
thrombosis)
Infancy : Coarctation of aorta
Primary Hypertension
Rare: Endocrine origin : Pheochromocytoma, Cushing’s, CAH

31. Clinicalfeaturesand
complications
 Most are asymptomatic or have non specific symptoms like
irritability, FTT, feeding problems , seizures, respiratory
distress, In older children(decreased scholastic performance)
 Hypertensive emergency: HTN with end organ damage
(Hypertensive encephalopathy, IC bleed, Acute LV failure ,
Renal failure)
 Hypertensive Urgency: HTN without end organ damage

32. Management
 Primary Hypertension : Lifestyle modification with weight
reduction, increased physical activity and dietary changes – trial given
for 6 months
 Secondary hypertension: HTN in Children with
1) Comorbid condition (DM,CKD, Dyslipidemia)
2) Target organ damage
3) Failure of BP to decline <95th centile despite lifetstyle modification
for 6 months
Commonly used meds include ACEi, CCB, Vasodilator , BB, Thiazide diuretics

33. CourseinCurrent
Hospital
History reassessed:
 History of paintball few days back – No direct trauma to chest
and abdomen
 Notable history of heat intolerance and night sweats with
history of Acne
 Right upper lobe Pneumonia – 10 months prior to current
admission
 Normal growth and development, received all routine
vaccines, no drug allergies

34. Course inCurrent
Hospital
• Medications included:
 Doxycycline & Topical tretinoin, Clindamycin &
Benzoyl peroxide, Zolmetriptan, Ondansetron
• Family history:
 Father and Paternal grandparents – Hypertension
 Maternal aunts – Migraine
 Mother and brother - Healthy

35. Drugs
DRUG DOXYCYCLINE TRETINOIN ZOLMITRIPTAN ONDANSETRON
CLASS Tetracyclines Retinoids Triptans Antiemetics
MOA Inhibits protein
synthesis (30S)
Form of vitamin A 5HT1d/1b receptor
agonists
5HT3antagonist
PHARMACOKINETICS 100% absorption GIT
Excreted in Feces
T1/2 : 18-24hours
100% absorption S/c
Metabolized by MAO-A
Excreted in Urine
T1/2 : 2hours
60% absorption oral
Metabolized by CYP
enzymes, Excreted in
Feces and Urine
T1/2 : 3-5hours
USES Veneral disease(LGV,
GI, Chlamydial),
Atypical pneumonia,
Rickettsial
Acne, APL , Oral
Leukoplakia
Migraine prophylaxis Chemotherapy induced,
Drug /diseased induced
PONV
ADVERSE EFFECTS Epigastric tenderness,
Phototoxicity , Teeth
and bone discoloration
,HSR
Dryness of skin ,eye,
nose, mouth
,pruritus, epistaxis,
Musculoskeletal
symptoms
C/I:
IHD,HTN, Epilepsy,
Pregnancy
S/E: Tightness in head ,
chest, dizziness,
bradycardia, HTN (less
clinical imp)
Headache, dizziness
(common)
Bradycardia,
Hypotension ,Chest
pain and Allergies less
common

36. Coursein Current
Hospital
(Cont.)
 Personal history:
 Good in academics, performed well in school, No illicit
drug/substance abuse
• O/E:
 Pale, diaphoretic & tired looking
 In distress because of pain
 Spoke in brief with frequent hiccups
 Normal temp – 36.6°C
 HR – 126/min (Tachycardia)
 BP – 90/44 (@5th centile)
 SpO2: 100% via nasal prongs at 4 L/min, RR: 15/min

37. Examination
(Cont.)
 P/A: Non distended with marked tenderness in right upper
quadrant and Right flank with rebound tenderness and guarding
 Skin: Normal and Warm,clammy with Inguinal hyperpigmentation
No café au-lait spots

38.  Conditions causing Inguinal hyperpigmentation: Acanthosis Nigricans
Eg: Type 2 DM (Insulin resistance), Hormonal disorders (Addison’s disease,
hyperthyroidism, adrenal tumors, Drugs (High dose Niacin, OCP), Gastric and
colon cancers.
 Hyaline Casts in Urine: Nonspecific finding
Dehydration, Diuretic use ,Vomiting , Renal tubular Acidosis, Nephrotic
syndrome

39. Labinvestigation
 Leucocytosis(WBC:27,140cells/dl)
 Serum Lactate 3.4mmol/L (Normal Range :0.5-2.0)
 Elevated Creatinine(1.64mg/dl)
 Elevated Troponin T levels (188mg/ml)
 Elevated Blood glucose(241mg/dl)
 Urine analysis: Trace ketones,1+ blood,<5 WBC/HpF, No
hematuria

40. Renalfailure
Increase in Serum
creatinine ≥0.3mg/dl from
baseline within 48hours
OR
Increase in Serum
creatinine ≥ 1.5 times from
baseline within prior 7 days
OR
Urine Volumes ≤
0.5ml/kg/hr for 6 hours
PARAMETERS Pre-Renal AKI Renal AKI
Sediment Hyaline cast Granular,WBC,RBC,
Cellular casts
Protein None Minimal or increased
Urine sodium (mEq/L) <20 >30
Urine osmolality
(mOsm/Kg)
>400 <350
FeNa <1 >1

41. POSITIVE
FINDINGS
16 YEAR OLD , MALE:
 HEADACHE since 1 year 5 months, episodic; with nausea,vomiting and
tunnel vision (?Signs of raised ICT/ ?Aura); family history for migraine
 ABDOMINAL PAIN sudden onset with marked tenderness in right upper
quadrant and Right flank & rebound tenderness with guarding;
 HYPERTENSION (>99th centile) ,ECG showed biventricular enlargement; with
elevated creatinine, acidosis and elevated blood glucose; family history for
hypertension
 Heat intolerance , Inguinal hyperpigmentation and night sweats
 Child is sick looking, In distress and Spoke in brief with frequent Hiccups;
Tachycardic with blood pressure at 5th centile after Labetalol infusion.

42. DIFFERENTIALS
1)Acute Abdomen: Appendicitis/Cholecystitis/Bacterial
enterocolitis/peritonitis
2)Hypertension with Abdominal pain :
 Vascular : Coarctation of aorta
 Renal : Nephritic syndrome, Renal artery Stenosis, Vasculitis
 Endocrine: Cushing's Syndrome, Hyperthyroidism, Pheochromocytoma
 Neurologic: Increased Intracranial pressure (Chronic SDH)
 Metabolic : Systemic hypertension, DKA, Porphyrias

43. FinalDiagnosis
Mixed migraine disorder with Aura
Diabetic Ketoacidosis (Hyperglycemia,Ketonuria,Acidosis)
Pheochromocytoma (Hypertension, Headache,Hyperglycemia)