When listening for hoofbeats, sometimes there are zebras—an interesting case of a teenager with edema and high blood pressure: Questions

Case presentation

A 15-year-old female presented to Children’s Healthcare of Atlanta at Scottish Rite Emergency Department with a history of edema and headaches. She had first noticed the headaches 1 week prior to hospital admission and had seen her primary care provider who prescribed migraine medication. Over the next few days, she noticed swelling in her face and extremities. She initially presented to an outside urgent care center with a blood pressure of 168/125, and microscopic hematuria and proteinuria were noted on urinalysis. She was subsequently transferred to Children’s Healthcare of Atlanta at Scottish Rite Emergency Department for further evaluation and possible inpatient hospitalization. En route to the emergency department, she was given doses of nifedipine and furosemide, to which she showed a therapeutic response, bringing her blood pressure (BP) down to 145/110 on repeat measurement.

The patient was admitted to the pediatric nephrology service with an initial diagnosis of presumed acute glomerulonephritis. Physical examination also revealed facial edema, a benign flow murmur, and 2+ pretibial edema of her lower extremities. Serologies for streptococcal antibodies, ANA, and C3/C4 complement levels were ordered, and the patient was placed on a sodium-restricted diet with scheduled doses of diuretic and antihypertensive medications for blood pressure control.

Questions

• 1) Are there any other studies that one might consider in this teenage female?

• 2) Are there any treatment considerations that should be addressed?