CASE PRESENTATION
This is a 30-year-old Caucasian male with biopsy confirmed glomerular basement disease diagnosed 3 months prior to presentation, with past medical history of tobacco use disorder. He received treatment with  hemodialysis (HD), glucocorticoids, and oral cyclophosphamide for anti-GBM disease treatment, as well as valsartan, amlodipine, and carvedilol for blood pressure control. He presented to the ED for nausea and non-bloody non-bilious vomiting with associated frontal headaches and photophobia. His BP was 184/124 and physical exam showed right lower quadrant tenderness, but otherwise was unremarkable and without any focal neurological deficits. His course was complicated by two witnessed grand mal seizures in the ED lasting 45 seconds and 25 seconds respectively which were controlled with lorazepam and levetiracetam. He was admitted to the intensive care unit (ICU) where his BP was controlled by the addition of clonidine and bumetanide to his outpatient regimen. Amlodipine was discontinued on admission due to concern that it may have caused immune thrombocytopenic purpura (ITP) as he was thrombocytopenic (Table 1). He was eventually stabilized and kept in the hospital for 3 days for further work-up. He was ultimately discharged on valsartan, carvedilol, clonidine, minoxidil, bumetanide, and continued HD.
Two months later, the patient was brought in by emergency medicine services (EMS) after an unwitnessed fall and his second presumed seizure. At this time, he was still on HD three times per week (prednisone and cyclophosphamide had been discontinued) and his BP regimen was adjusted in the outpatient setting to losartan, carvedilol, clonidine, and minoxidil. His family heard a loud thud from another room and found him on the floor minimally responsive but awake. On EMS arrival, the patient was complaining of a headache and was noted to be mentally altered. His BP at that time was 218/130 and on route to the ED, EMS witnessed a grand mal seizure of one-minute duration. In the ED, his BP remained elevated at 209/137 and he was mildly confused and agitated, presumed due to post-ictal state. He had a GCS of 15, 5/5 muscle strength in all extremities, intact sensation to light touch, and no focal neurological deficits. He received multiple doses of lorazepam in the ED to combat seizure activity and was intubated for airway protection. He was then admitted to the ICU for further seizure work-up and blood pressure control with a nitroglycerin drip.