Case 1: An unusual cause of headaches and priapism in a teenager

A previously healthy 15-year-old boy presented to the paediatric emergency department after suffering from three weeks of headache, two weeks of neck pain and one week of intermittent blurry vision. The headache was described as a throbbing, diffuse pain, which was worse in the mornings, but did not wake the patient from his sleep. The headache was not associated with nausea or vomiting, and there was no fever. In the three months leading up to his presentation, the patient had two episodes of priapism that resolved, and he was treated three times with metronidazole for presumed balanitis. He also had lower back and neck pain that was thought to be muscle-related. There was no known family history of headaches or migraines. On examination, his initial vital signs showed a normal blood pressure of 106/61 mmHg, a heart rate of 57 beats/min, and a temperature of 34.8°C. He was pale, alert and in no acute distress, with a Glasgow Coma Scale rating of 15. The patient had normal respiratory, cardiovascular, musculoskeletal and abdominal examinations (although the spleen was subsequently found to be mildly enlarged on abdominal ultrasound), and had no bruises or petechiae. His neurological examination showed that his sensations, motor functions, cranial nerves, cerebellar function and reflexes were normal. A fundoscopy revealed papilledema bilaterally; his visual acuity was 20/30 bilaterally. Initial investigations included an unenhanced computed tomography scan of the head, which was within normal limits. A lumbar puncture was performed and there was an elevated opening pressure of 48 cm of water. A diagnosis of idiopathic intracranial hypertension was made, and he was discharged on acetazolamide. The patient returned to the emergency department five days following his initial visit, with a complaint of early morning headache with associated blurry vision. His physical examination was unchanged. His magnetic resonance imaging and magnetic resonance venography scans were normal. The patient’s complete blood count revealed an elevated white blood cell count of 480×109/L, with a differential showing: lymphocytes 8×109/L, monocytes 0×109/L, eosinophils 1.6×109/L, polymorphs 27.2×109/L, bands 129.60×109/L, metamyelocytes 68.8×109/L, myelo-cytes 193.6×109/L, promyelocytes 44.6×109/L and immature cells 9.6×109/L, as well as a decreased hemoglobin level (94 g/L) and platelet count (130×109/L).

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