A 20-year-old man with sickle cell disease, and a recent history of glomerulonephritis and renal impairment presented to the accident and emergency department with a 1-day history of confusion followed by convulsion. He had not previously received therapy with any medications. On presentation, he was found to have a BP of 200/140 mm Hg. In the emergency department, he had to be intubated for status epilepticus and was then admitted to our ICU.
In the ICU, both his BP and the convulsion were difficult to control. The mean arterial BP was always approximately 120 mm Hg despite therapy with IV labetolol, and the enteral administration of captopril, diltiazem, propranolol, and hydralazine. He continued to experience seizures for 3 days thereafter whenever sedatives were interrupted on a daily basis. A brain CT scan (Fig 1
) showed a hypodense area in the cerebellar region, which was interpreted by radiologist as an area of infarction. Additional workup showed a very high vanillylmandelic acid level, suggestive of pheochromocytoma. A follow-up MRI 1 week later (Fig 2
) showed marked improvement in appearance in relation to the cerebellar lesion first seen on the brain CT scan.