A child presenting with severe hypertension and circulatory failure, a diagnostic conundrum: Questions

Excerpt

A 4-year-old Caucasian girl was referred to the pediatric intensive care unit (PICU) with persistent nonbillious vomiting (>20 times) during the prior 24 h and decreased responsiveness. She had no history of any major illness. The vomiting started the day before and was not accompanied by diarrhea, fever, or respiratory symptoms. Hours before admission, she had become less responsive while vomiting persisted, prompting her parents to seek professional medical help. There were no other siblings, and her father had been diagnosed with essential hypertension a couple of years previously. They had not visited countries outside of Western Europe in recent years. The child had received no recent vaccinations or medication and was vaccinated according to national guidelines. Growth and developmental milestones were normal. At clinical examination, a lethargic and very ill-looking girl with poor peripheral circulation (cool and pale-gray extremities) was seen. She was tachycardic (220 beats/min), with a blood pressure (BP) of 150/80 mmHg and saturation of 92%. Saturation remained low even with oxygen supplementation (15 L/min). No rash, petechia, or purpura were noticed, and nuchal rigidity was absent. At auscultation, bilateral crepitations were recorded. No abnormal cardiac murmurs were noticed, and the rest of the clinical examination showed no abnormalities. She weighed 21 kg and was 110-cm tall. …