Case by Nikki Animasaun MD, CNH Pediatric Emergency Medicine Fellow

An 11-year-old female with history of recent sepsis in the setting of recent group A strep skin and soft tissue infection presents with altered mental status and possible seizure activity. Per grandma, yesterday, the patient developed a headache which continued until this morning. This morning after eating breakfast she had an episode of non-bloody, non-bilious emesis. Shortly after grandma found the patient lying on the floor unresponsive. Grandma endorses possible abnormal movement and the patient’s eyes were open but no eye deviations. Upon arrival, EMS found the patient still unresponsive with nystagmus and shaking. EMS administered 5mg of Midazolam at which time the shaking stopped and the patient became post-ictal. No fever, URI symptoms, eye pain, vision changes, chest pain, abdominal pain, or rash. Endorses facial puffiness for the past few days that is improving.

Of note, the patient was discharged from the hospital 4 days ago. At that time, she presented for an axillary abscess. Underwent four I&D and is s/p multiple antibiotic treatments (Vancomycin, Ampicillin-Sulbactam, Ceftriaxone, Clindamycin, and Cefazolin). The wound grew group A strep pyogenes. MRSA negative. CT right upper extremity at the time also revealed abdominal ascites and a small right pleural effusion concerning for diffuse fluid overload. She was discharged on Amoxicillin (day 6 of 10).

PMH: Seasonal allergies
PSHx: I&D
Meds: Amoxicillin
Allergies: NKDA
Immunizations: UTD
Family Hx: No family history of HTN or kidney disease

T36.5, HR 96, RR 30, BP 148/112, 100% on RA

General:  Sleepy but easily arousable with stimulation
Skin:  Warm, dry, no rashes 
Eye:  PERRL, EOMI, Normal conjunctiva
Ears, nose, mouth, and throat:  No pharyngeal erythema or exudate.  Moist mucosal membranes 
Cardiovascular: RRR, No murmurs/rubs/gallops, <2 sec capillary refill
Respiratory:  CTAB. Good aeration bilaterally. No increased WOB.
Gastrointestinal:  Soft, non-tender, non-distended, no guarding or rebound. No palpable masses. No hepatosplenomegaly. 
Neurological: Alert. No neurological deficits. Normal speech. Normal gait.

BP rechecked multiple times and the patient still had SBP >140s. Discussed the case with the pharmacist who recommended hydralazine. A dose of hydralazine 4mg (0.1mg/kg) without improvement. Gave another dose of hydralazine 4mg with an improvement of the BP to 127/99.

Nephrology consulted and recommended:

-Amlodipine 5mg daily
-1st line PO Isradipine 2.5mg q8 for SBP >130s
-2nd line IV Labetalol 8mg q4 for SBP >130s
-3rd line IV hydralazine 8mg q6 for SBP >130s.

Labs obtained. WBC 18. CRP 0.45. Electrolytes, thyroid function panel, C3 & C4 levels all normal. UA with 2+ blood, 1+ protein, WBC 12, no bacteria, trace LE. RFP normal. Utox positive for benzos. Renal US showed bilateral echogenicity of the kidneys.

Had another episode of SBP> 130 so Isradipine 2.5mg was given.

Neurology consulted and recommended a 2-hour EEG. The patient’s mental status at this point is improved and she is taken to CT.