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.