We report an 8-year-old boy with bilateral lower motor neuron palsy who initially presented to our department with a 4-day history of headaches described as bilateral heaviness in the frontal area and was responding to paracetamol. He had recently recovered from chickenpox a few days prior to this presentation. The headache was not associated with fever, dizziness, vertigo or abnormal behaviour. There was no history of clumsiness or falling and his gait and speech were appropriate. Examination showed a blood pressure (BP) of 116/80 mm Hg and 123/67 mm Hg and no focal neurological signs. There were a few scabbed chickenpox lesions. Systemic examination was otherwise unremarkable. Following a period of observation, his headache subsided with some paracetamol and he was allowed home with advice on when to return.
He returned to the ward 3 days later still having headaches, which became worse and required more pain relief. Parents reported that his lower lip went numb followed by numbness of his upper lip and he could not eat as he could not put his lips together and found it difficult to even suck through a straw. His parents reported that he was sleeping with his eyes half open. His BP was between 127/90 and 138/89 and his examination showed a bilateral lower motor neuron paralysis of his facial nerve. All other cranial nerves were intact, his motor system examination was normal, he had a normal gait and speech and co-ordination was normal. He had a few scars of chickenpox but no fresh vesicles and no lesions in his ears. Systemic examination was otherwise unremarkable.
He lives with both parents and a 5-year-old sister who are all healthy. He suffered with recurrent urinary tract infections and bilateral vesicoureteral reflux. Four years earlier a mercaptoacetyltriglycine reported the left kidney contributing 72% and the right kidney 28% of the renal function with no evidence of obstruction; however, there was reflux into the right ureter during micturition. A technetium dimercaptosuccinic acid scan (DMSA) showed similar uptake and loss of cortex from the upper and lower poles of the right kidney. He was no longer on prophylaxis as he had no recent urinary tract infections and is under annual review.
An ophthalmology opinion was obtained, which was satisfactory.
The regional paediatric neurology and nephrology departments advised to start him on losartan and if his BP became higher to give him a stat dose of nifedipine. He was also started on hypomellose eye drops. Overnight his BP measurements were between 122/80 mm Hg and 147/89 mm Hg.
Following transfer to the regional paediatric tertiary centre, a diagnosis of bilateral lower motor neuron facial palsy associated with raised BP with no other focal neurological signs was confirmed.