A 34 year old Chinese woman with limited scleroderma presented with rapid onset of mental confusion and generalised tonic-clonic seizures. Her blood pressure control had been unsatisfactory in the preceding 4 weeks despite the use of three anti-hypertensive agents, which included an angiotensin converting enzyme inhibitor. Malignant hypertension (blood pressure 240/140 mm Hg on admission) was evident, with typical fundoscopic abnormalities, microangiopathic haemolytic anaemia, and rapidly deteriorating renal function with acute oligouric renal failure (increase in serum creatinine from baseline of 86 to 495 …