A 21 year-old gentleman presented with complete visual loss in left eye for few minutes followed by persistent blurriness. He reported two months of headaches, two weeks of hematuria and transient left arm numbness for couple of minutes, a week before presentation. Past history significant for hypertension while in middle school. On arrival blood-pressure was 280/165. Examination noted flame-shaped retinal hemorrhages and grade 2 papilledema on the left eye in addition to mild petechial rash on bilateral shins.Reminder of the examination was unremarkable. Labs significant for platelet count 115,000/microliter(Normal:150,000-450,000/microliter), Lactate Dehydrogenase 547 Units/Liter(Normal:120-220 Units/Liter), haptoglobin 8 mg/dl(Normal: 14-258 mg/dl) and multiple schistocytes on peripheral smear. Urinalysis showed packed Red Blood Cells with proteinuria. Other relevant labs were unremarkable. MR Brain noted T2 FLAIR hyperintensities in bifrontal, brainstem associated with punctate area of diffusion restriction plus susceptibility weighted artifact in the right putamen. Based on MR brain, Posterior Reversible Encephalopathy Syndrome(PRES) was suspected with or without possible contribution from hypertension. 

On arrival anti-hypertensives were initiated resulting in immediate resolution of headaches. Plasma exchange was initiated on the second day with presumption of Thrombotic Thrombocytopenic Purpura(TTP) but absence of fever, modest thrombocytopenia prompted consideration of Malignant Hypertension(MH). Plasma exchange was stopped and ADAMTS-13 activity was later found normal. Patient was discharged on oral anti-hypertensives. 

At one month follow up, he had no complaints except some left eye blurriness. Repeat MR Brain at one month noted resolution of the T2 FLAIR hyperintensities.