Vomiting and altered mental status in an adolescent

It is two o'clock in the morning and you are working in the pediatric intensive care unit (PICU) when you receive a phone call from an outside hospital concerning a teenager who has ripped his clothes off at a local church. Although you're exhausted, you become captivated and want to hear more details.

The referring physician describes a 14-year-old teenager who was in his usual state of health until he developed abdominal pain and nausea earlier that morning while at church with his parents. The boy did not appear to be bothered by the pain, but upon exiting the church doors he became acutely confused, tore off his clothing, and had a few episodes of nonbloody, nonbilious emesis. He then began circling a car in the parking lot. He stumbled a few times but was able to pick himself up. Next, he began shouting unintelligible words and performing inappropriate actions. There was no evidence of seizure activity, trauma, or toxin exposure, but the patient was clearly not acting like himself, according to family and friends.

Emergency Medical Services (EMS) was immediately called to the scene. When they arrived, the patient was combative, but they were able to restrain him. Upon assessment, vital signs showed an elevated blood pressure of 140/70 mm Hg, a heart rate of 94 bpm, and respiratory rate of 18 bpm. He was partially disrobed and complaining of abdominal pain at the time.

Past medical history is significant for a nephrectomy at the age of 22 months for a stage II Wilms' tumor. During his treatment course he received dactinomycin (Cosmegen) and vincristine (Oncovin, Vincasar). According to the parents, the patient was doing well and was being followed by an oncologist. His last visit to the oncologist was during the summer of 1999, at which time he was normotensive with a blood pressure of 122/71 mm Hg. The remainder of his physical exam was unremarkable, including neurologic and fundoscopic examinations.

When the patient entered the emergency room his vitals demonstrated a blood pressure of 194/126 mm Hg, a pulse of 57, and a core body temperature of 94.8º F (34.9º C). He remained hypertensive on several readings until treatment was initiated. His altered mental status and elevated blood pressure made this a hypertensive emergency. In addition, a low heart rate and an elevated blood pressure made his presentation concerning for increased intracranial pressure as part of Cushing's triad. But what was the origin of these signs and symptoms?

The patient continued to complain of abdominal pain and was still confused in the emergency room. The physicians at the outside hospital had described his mental status as "waxing and waning" and noted him to be "combative then difficult to arouse and then alert." At the time of the call, he was no longer answering questions appropriately. Restraints were needed due to the combative nature of the patient. His physical examination was also significant for diffuse abdominal tenderness and hypoactive bowel sounds. His cardiovascular and respiratory exams were unremarkable.

Initial laboratory analysis at the outside hospital was significant for a urinalysis specific gravity of 1.030, 2+ proteinuria, and no leukocyte esterase or nitrites. A complete metabolic panel revealed normal electrolytes, blood urea nitrogen of 20 mg/dL (normal is 7-25 mg/dL), creatinine of 1.0 mg/dL (normal is 0.4-1.4 mg/dL), and slightly elevated glucose of 155 mg/dL (normal is 65-125 mg/dL). CBC was unremarkable, with a white blood cell count of 8.9 x 103/µL with 48% polymorphonuclear cells, 36% lymphocytes, and 12% monocytes. Urine toxicology screen was negative. Blood and urine cultures were also sent.

Is this emergent or urgent?

As you listen to the history, you begin to ponder this unusual case of hypertension and altered mental status. The outside hospital gave a primary diagnosis of hypertensive encephalopathy. You realize that while hypertension may be relatively uncommon in the pediatric population, a hypertensive crisis is a rare event. Hypertensive crises are divided into hypertensive emergencies and hypertensive urgencies. In a hypertensive emergency, there are elevations of systolic and diastolic blood pressure as well as end-organ damage. Examples of end-organ damage may include hypertensive encephalopathy and cerebral infarction. In a hypertensive urgency, which is more common, there are elevations of systolic and diastolic blood pressure without evidence of end-organ damage.¹