to the editor: I read this article with interest. However, the authors did not mention heavy metal poisoning as a possible etiology of elevated blood pressure in children. Elemental and inorganic mercury poisonings have been described as causes of hypertension.^1,2 Less common metals, such as arsenic and thallium, can also cause hypertension.^3,4 Although lead poisoning is known to cause hypertension in adults, it does not seem to do so in children.⁵

It is important to identify heavy metal poisoning as an etiology of elevated blood pressure because it is potentially treatable. Heavy metal intoxication can be evaluated with 24-hour urine screening. Treatment depends on the particular metal involved, but identification and removal from the source is paramount. Decisions on chelation should be made in consultation with a regional poison control center or medical toxicologist.

in reply: We appreciate Dr. Thornton's comments on heavy metal poisoning as a possible cause of elevated blood pressure in children. Heavy metal poisoning has been described in case reports as causing hypertension in children, but this is relatively rare and does not need to be included in the standard workup for secondary etiologies of hypertension. If heavy metal intoxication is suspected based on history or physical examination findings, then a 24-hour urine sample should be considered.