This case highlights the complexity of managing a pediatric patient presenting with hypertensive emergency. Hypertensive emergency is characterized by stage II hypertension with signs of end-organ damage. In this case, the patient presented with signs of CNS dysfunction (seizure and altered mental status). Most learners were also concerned for some other intracranial pathology (ie abscess, hemorrhage, stroke). Given the prior pleural effusions, ascites, and strep infection, differential also included renal failure leading to hypertension, possibly in setting of post-streptococcal glomerulonephritis.

Most learners agreed with hydralazine as an initial agent but to be mindful about not rapidly dropping the blood pressure too quickly due to concerns for maintaining cerebral perfusion in cases of increased cranial pressure. Ultimately a CT Brain was obtained that showed findings consistent with hypertensive encephalopathy/PRES, characterized by low-attenuation areas in the parietal lobes. An MRI brain confirmed PRES with posterior edema in bilateral parietal and occipital regions. The patient was admitted to the PICU and returned to baseline and discharged home on amlodipine.