Author Topic: Case (48)  (Read 4782 times)

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Case (48)
« on: December 26, 2008, 01:03:58 PM »
A 25-year-old woman, who had episodes, typically lasting less than 10 s, of feeling lightheaded, occasionally nauseous, and suddenly and alarmingly unwell. She sometimes felt faint, and occasionally lost consciousness. She had collapsed on more than one occasion, but had no movements typical of epilepsy.

The frequency of her episodes varied considerably; sometimes, she had several episodes a week. Her episodes had begun 10 years previously, and remained unexplained, despite hospital admissions in 2001 and 2007. She had been subjected to many investigations, many more than once.

Blood tests—including a full blood count, a standard biochemistry screen, thyroid function tests, a pituitary hormone profile, an autoantibody screen (including, to screen for coeliac disease, antibodies to the endomysium, and IgA antibodies to reticulin), an ESR, a short synacthen test, an oral glucose tolerance test, and concentrations of glucose (after an overnight fast), C-reactive protein and immunoglobulins; chest radiography; standard and 24 h electrocardiograms (ECGs); and 24 h ambulatory bloodpressure recordings had all given unremarkable results.

In November, 2007, an electroencephalogram (EEG) had shown no evidence of epilepsy.
We reviewed the history. Apart from her faints, the patient’s medical, psychiatric, and family history was unremarkable. Her only regular medication was the contraceptive pill. She had never smoked, drank less than ten units of alcohol a week, and said she had never used
illicit drugs.

On questioning, she remarked that her episodes tended to occur when she ate certain kinds of food, especially sandwiches, or drank fizzy drinks: she had last collapsed when, uncharacteristically, eating a sandwich while driving. As a result, she tended to avoid
eating: indeed, her low weight had been investigated, in 2000, before her faints.

She had no physical or psychiatric features of anorexia nervosa, nor any symptoms of gastrointestinal illness. She weighed only 46∙5 kg; her body-mass index was 17∙9 kg/m. Her resting pulse rate was regular, at 60 beats per min; her blood pressure was 116/70 mm Hg, without a postural drop. We kept her in hospital, and continuously monitored her ECG and blood pressure. We offered her a sandwich.

What is your diagnosis?
What is the machanism of fainting?
What is the treatment of this case?


"you never cure a patient, you treat pain often but you always comfort the patient."
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Offline Mustafa

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Re: Case (48)
« Reply #1 on: December 26, 2008, 05:36:47 PM »

Salam

1. Swallow sncope, also called deglutition syncope.
2. It may be caused by altered feedback in vagal reflexes -- in which the afferent pathway, from the esophagus, terminates in the nucleus tractus solitarius, and the efferent pathway runs from the medulla to the heart -- or by vagal hypersensitivity. This phenomen triggers AV block.
3. Different patients get different dysrhythmias because the anatomy and functioning of cardiac vagal innervation varies considerably. Swallow syncope has been treated with sympathomimetic agents, such as ephedrine and isoprenaline, but results have been inconsistent; pre-treatment with atropine may be helpful. Cardiac pacing, when necessary, has been shown to be effective in an increasing number of case reports. Any comorbid illness should be treated. Patients with swallow syncope can languish for years because the diagnosis is little known—although a case report on it was published in The Lancet, 50 years ago.

wa salam


Mustafa

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Re: Case (48)
« Reply #2 on: December 27, 2008, 10:04:58 PM »
Thanks Mustafa for the answer

Welcome back
Hajan Mabruur wa Sacyan Mashkuur
"you never cure a patient, you treat pain often but you always comfort the patient."
www.somalidoc.com


 

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