Abstract
An otherwise healthy male in his twenties suffering from a four-month history of headaches, four-day history of visual disturbance and hypertension was referred to the emergency department by his general practitioner. The patient remained persistently hypertensive following admission, with systolic blood pressures exceeding 200 mm Hg, and ophthalmological examination revealed changes consistent with those of hypertensive retinopathy (Grade IV). Computed tomography (CT) and subsequent magnetic resonance imaging of the brain were conducted, both demonstrating findings suggestive of idiopathic intracranial hypertension (IIH). Collectively, however, the clinical picture was more consistent with ‘hypertensive emergency’ than IIH, particularly given the discordance of the patient’s phenotype with that typically seen in IIH. This prompted investigation into the cause of secondary hypertension, which revealed elevated plasma normetanephrines. A mass suspicious for a para-aortic paraganglioma was subsequently demonstrated on CT. Surgical excision of the mass, which was histopathologically consistent with a paraganglioma, resulted in rapid resolution of the hypertension and symptoms. This case illustrates (i) the importance of exploring for secondary causes of hypertension in individuals presenting with a suspected hypertensive emergency, particularly young individuals; (ii) emphasises the lack of specificity of neuroimaging findings traditionally associated with IIH; and (iii) reveals that abdominal paragangliomas can radiologically mimic idiopathic intracranial hypertension, manifesting with these same neuroimaging findings. This case will be discussed in relation to published information on idiopathic ICH.
