an interesting case of syncope august 2005 white 10, team c – massachusetts general hospital,...

An interesting case An interesting case of syncopeof syncope

August 2005August 2005

White 10, Team C – Massachusetts General White 10, Team C – Massachusetts General Hospital,Hospital,

Boston – MA, USABoston – MA, USA

Lorenzo AzzaliniLorenzo Azzalini University of Padua University of Padua Medical School, ItalyMedical School, Italy

History of present illnessHistory of present illness DAK is a 78 y.o. male with history of CAD, PE, DAK is a 78 y.o. male with history of CAD, PE,

recurrent DVT, COPD, DM, recurrent DVT, COPD, DM, presenting with presenting with syncopesyncope..

The pt. reports that he was in his usual state of The pt. reports that he was in his usual state of health on the morning of the admission.health on the morning of the admission.

He took his medications but had not yet eaten He took his medications but had not yet eaten breakfast, and he was sitting in his chair. He breakfast, and he was sitting in his chair. He stood up from the chair, took two steps, and the stood up from the chair, took two steps, and the next thing he remembers is that he was hanging next thing he remembers is that he was hanging onto his TV, after having fallen forward onto it.onto his TV, after having fallen forward onto it.

He noticed pain in his head and in his L leg. He noticed pain in his head and in his L leg. After this loss of consciousness, the pt. reported After this loss of consciousness, the pt. reported feeling dizzy, confused and having difficulties feeling dizzy, confused and having difficulties walking.walking.

He denied chest pain, palpitations, SOB, nausea, He denied chest pain, palpitations, SOB, nausea, vomiting or diaphoresis.vomiting or diaphoresis.

History of present illnessHistory of present illness

The pt. called EMS, who transported The pt. called EMS, who transported him to the MGH ED.him to the MGH ED.

There, he had a laboratory evaluation There, he had a laboratory evaluation that revealed –ve cardiac enzymes, no that revealed –ve cardiac enzymes, no significant electrolytes abnormalities, no significant electrolytes abnormalities, no urinary infections, and INR of 2.9 (he is urinary infections, and INR of 2.9 (he is taking Coumadin for recurrent DVTs). taking Coumadin for recurrent DVTs). His pacemaker was funcioning normally, His pacemaker was funcioning normally, without any recorded events the without any recorded events the morning of the admission to explain the morning of the admission to explain the syncope.syncope.

History of present illnessHistory of present illness Chest x-ray showed cardiomegaly.Chest x-ray showed cardiomegaly. Head CT did not reveal any acute bleeding.Head CT did not reveal any acute bleeding. Plain x-rays of the left leg showed no Plain x-rays of the left leg showed no

fractures.fractures. The patient was then admitted for further The patient was then admitted for further

work-up of his syncope.work-up of his syncope. At the admission on White 10, he denied At the admission on White 10, he denied

any pain, except in his L leg, stated that he any pain, except in his L leg, stated that he felt “a little light-headed”, and reported felt “a little light-headed”, and reported that he was unsure of getting up and that he was unsure of getting up and walking, because of unsteadiness and fear walking, because of unsteadiness and fear of the L leg injury.of the L leg injury.

History of present illnessHistory of present illness The pt. reports that he has only had one The pt. reports that he has only had one

episode like this in the past, a little less episode like this in the past, a little less than a year ago, when he went into an than a year ago, when he went into an atrial arrythmia.atrial arrythmia.

He denied orthopnea, PND, history of He denied orthopnea, PND, history of stroke or any symptoms of weakness, but stroke or any symptoms of weakness, but reported SOB on exertion after walking for reported SOB on exertion after walking for a small distance.a small distance.

He reported that he had had several He reported that he had had several occasions where he had noticed that he felt occasions where he had noticed that he felt to his left side when walking. These to his left side when walking. These episodes resolved on their own and episodes resolved on their own and happened infrequently.happened infrequently.

Review of systemsReview of systems No fever, chills, nausea, vomiting, chest No fever, chills, nausea, vomiting, chest

pains, palpitations.pains, palpitations. No orthopnea/PND.No orthopnea/PND. No cough/hemoptysis/wheezing/sore No cough/hemoptysis/wheezing/sore

throat/rash.throat/rash. No hematochezia/melena.No hematochezia/melena. No alterations of mental status.No alterations of mental status. No slurring of speech or unilateral No slurring of speech or unilateral

weakness.weakness. No dysuria.No dysuria. No exposures/ingestions/recent travel.No exposures/ingestions/recent travel.

Past medical historyPast medical history

CADCAD – Angiography (2/2000), – Angiography (2/2000), showing diffuse coronary disease, showing diffuse coronary disease, without focal stenosis. Echo without focal stenosis. Echo (10/2004), showing EF 57% with (10/2004), showing EF 57% with LVH and without wall motion LVH and without wall motion abnormalities or significant valvular abnormalities or significant valvular disease. Dipyridamole MIBI 3/2005, disease. Dipyridamole MIBI 3/2005, showing normal myocardial showing normal myocardial perfusion and LVEF 46%.perfusion and LVEF 46%.

Past medical historyPast medical history Atrial fibrillationAtrial fibrillation – s/p ablation. With – s/p ablation. With

pacemaker (VVIR). Interrogation on pacemaker (VVIR). Interrogation on admission showed AF with ventricular admission showed AF with ventricular rate of 30 bpm.rate of 30 bpm.

PE/DVTsPE/DVTs – Pulmonary embolism (1970), – Pulmonary embolism (1970), history of recurrent DVTs. On chronic history of recurrent DVTs. On chronic Coumadin. IVC filter.Coumadin. IVC filter.

DMDM – oral therapy and diet. Controlled. – oral therapy and diet. Controlled. COPDCOPD GlaucomaGlaucoma

Past medical historyPast medical history

s/p cornea transplants/p cornea transplant s/p appendectomys/p appendectomy s/p hemorrhoidectomys/p hemorrhoidectomy CholelithiasisCholelithiasis

Medications on Medications on admissionadmission

Rosuvastatin (Crestor) 20 mg QDRosuvastatin (Crestor) 20 mg QD Glipizide 5 mg QDGlipizide 5 mg QD Pantoprazole (Protonix) 40 mg QDPantoprazole (Protonix) 40 mg QD Warfarin (Coumadin) 10 mg QAMWarfarin (Coumadin) 10 mg QAM Isosorbide mononitrate sustained Isosorbide mononitrate sustained

release 120 mg QDrelease 120 mg QD ASA 325 mg QDASA 325 mg QD Atenolol 50 mg QDAtenolol 50 mg QD

Medications on Medications on admissionadmission

Furosemide (Lasix) 20 mg QDFurosemide (Lasix) 20 mg QD Lisinopril 20 mg QDLisinopril 20 mg QD Beclomethasone nasal spray one puff Beclomethasone nasal spray one puff

BIDBID Albuterol PRNAlbuterol PRN

AllergiesAllergies – past history of nausea on – past history of nausea on penicillin, but on admission the pt. claims penicillin, but on admission the pt. claims he had no problems with penicillin.he had no problems with penicillin.

Social historySocial history – History of heavy drinking – History of heavy drinking and smoking (120 pack-year), but quitted and smoking (120 pack-year), but quitted 35 years ago. Used to work as a Merchant 35 years ago. Used to work as a Merchant Marine and commercial fisherman. Marine and commercial fisherman. Originally from Ireland. Widow. Lives alone.Originally from Ireland. Widow. Lives alone.

Familial historyFamilial history – Father died of MI, – Father died of MI, mother of “booze”, brothers of lung cancer.mother of “booze”, brothers of lung cancer.

Physical examPhysical exam Vital signs – T 96.6, HR 60, BP 144/80, RR 20, Vital signs – T 96.6, HR 60, BP 144/80, RR 20,

SaOSaO22 99% RA 99% RA Orthostatics – supine BP 115/62, HR 62; sitting Orthostatics – supine BP 115/62, HR 62; sitting

BP 126/75, HR 66; standing BP 124/71, HR 70BP 126/75, HR 66; standing BP 124/71, HR 70 General – obese, non-apparent distressGeneral – obese, non-apparent distress HEENT – PERRL, EOMI, sclera anictericHEENT – PERRL, EOMI, sclera anicteric Neck – supple, left mass, no carotid bruits, JVP Neck – supple, left mass, no carotid bruits, JVP

difficult to appreciatedifficult to appreciate Nodes – no cervical or supraclavicular LADNodes – no cervical or supraclavicular LAD CV – RRR, S1 & S2 nl, 1/6 systolic murmur CV – RRR, S1 & S2 nl, 1/6 systolic murmur

heard best at LUSB. No S3, S4.heard best at LUSB. No S3, S4.

Physical examPhysical exam Chest – fine crackles at L base, poor air Chest – fine crackles at L base, poor air

movement bilaterally, otherwise CTA.movement bilaterally, otherwise CTA. Abdomen - +BS, NT, ND. No HSM. No Abdomen - +BS, NT, ND. No HSM. No

peritoneal signs.peritoneal signs. Ext – 1+ edema bilaterally w/ evidence of Ext – 1+ edema bilaterally w/ evidence of

chronic venous stasis changes, hematoma chronic venous stasis changes, hematoma L kneeL knee

Skin – no rashesSkin – no rashes Neuro – A&Ox3; CN II-XII intact, Neuro – A&Ox3; CN II-XII intact,

Romberg –ve, FTN showed dysmetria, Romberg –ve, FTN showed dysmetria, poor rapid alternating movements.poor rapid alternating movements.

Labs and studiesLabs and studies

BloodBlood

NaNa++ 140140 (135-145)(135-145) mmol/lmmol/l

KK++ 4.74.7 (3.4-4.8)(3.4-4.8) mmol/lmmol/l

ClCl-- 110 (H)110 (H) (100-108)(100-108) mmol/lmmol/l

COCO22 26.326.3 (23.0-(23.0-31.9)31.9)

mmol/lmmol/l

BUNBUN 30 (H)30 (H) (8-25)(8-25) mg/dlmg/dl

CreatininCreatininee

1.31.3 (0.6-1.5)(0.6-1.5) mg/dlmg/dl

GlucoseGlucose 9797 (70-110)(70-110) mg/dlmg/dl


BloodBlood

CK-MBCK-MB NegativNegativee

NegativeNegative

Troponin-ITroponin-I NegativNegativee

NegativeNegative


BloodBlood

RBCRBC 4.17 (L)4.17 (L) (4.50-(4.50-5.90)5.90)

·10·1099/mm/mm33

HCTHCT 36.5 (L)36.5 (L) (41.0-(41.0-53.0)53.0)

%%

HbHb 11.5 (L)11.5 (L) (13.5-(13.5-17.5)17.5)

g/dlg/dl

MCVMCV 8888 (80-100)(80-100) flfl

MCHMCH 27.527.5 (26.0-(26.0-34.0)34.0)

pgpg

MCHCMCHC 31.431.4 (31.0-(31.0-37.0)37.0)

g/dlg/dl

RDWRDW 15.1 (H)15.1 (H) (11.5-(11.5-14.5)14.5)

%%


BloodBlood

WBCWBC 7.57.5 (4.5-11.0)(4.5-11.0) ·10·1033/mm/mm33

PLTPLT 168168 (150-350)(150-350) ·10·1033/mm/mm33

PTPT 21.3 (H)21.3 (H) (11.3-(11.3-13.3)13.3)

ss

APTTAPTT 39.7 (H)39.7 (H) (22.1-(22.1-35.1)35.1)

ss


UrineUrine

Specific Specific gravitygravity

1.0251.025 (1.001-(1.001-1.035)1.035)

kg/l

pHpH 5.55.5 (5.0-9.0)(5.0-9.0)

WBC WBC screenscreen

NegativNegativee

NegativeNegative

NitriteNitrite NegativNegativee

NegativeNegative

AlbuminAlbumin 3+3+ NegativeNegative

GlucoseGlucose TraceTrace NegativeNegative

KetonesKetones NegativNegativee

NegativeNegative

Occult Occult bloodblood

TraceTrace NegativeNegative

ChesChestt

X-X-RayRay

Chest X-RayChest X-Ray

Stable moderate cardiomegaly, with Stable moderate cardiomegaly, with no evidence for pulmonary edema.no evidence for pulmonary edema.

Head Head CTCT

Head CTHead CT

No evidence of traumatic injury or No evidence of traumatic injury or acute intracranial pathology.acute intracranial pathology.

ECGECG

V-pacedV-paced HR 60HR 60 No underlying coordinated atrial No underlying coordinated atrial

depolarizationdepolarization

Assessment and planAssessment and plan DAK is a 78 y.o. male with history of CAD, AF, DAK is a 78 y.o. male with history of CAD, AF,

PE/DVTs, on chronic coumadin, with syncopal PE/DVTs, on chronic coumadin, with syncopal episode and fall on the day of admission.episode and fall on the day of admission.

1)1) SyncopeSyncope The patient’s history points towards orthostatic The patient’s history points towards orthostatic

syncope. The pt. continued to have some dizziness syncope. The pt. continued to have some dizziness even though he was not orthostatic when he even though he was not orthostatic when he arrived at White 10, which lessens the likelihood arrived at White 10, which lessens the likelihood that orthostasis will be able to explain the whole that orthostasis will be able to explain the whole picture. Arrythmia is not likely the cause of the picture. Arrythmia is not likely the cause of the syncope, as the pacemaker did not show any syncope, as the pacemaker did not show any abnormal events. Neurologic etiology could be abnormal events. Neurologic etiology could be possible. Head CT was –ve for acute process, but possible. Head CT was –ve for acute process, but the patient did have suspicious signs and the patient did have suspicious signs and symptoms (dizziness, dysmetria, gait difficulty)symptoms (dizziness, dysmetria, gait difficulty)

Assessment and planAssessment and plan

PlanPlan Central telemetry overnightCentral telemetry overnight 250 cc bolus (normal saline)250 cc bolus (normal saline) Transcranial doppler to evaluate Transcranial doppler to evaluate

posterior circulationposterior circulation


2)2) HeartHeart Rhythm – monitor for any arrythmiasRhythm – monitor for any arrythmias Pump – last Echo revealed an EF of 57%. Pump – last Echo revealed an EF of 57%.

The patient does not clinically appear to The patient does not clinically appear to be in heart failure (no pulmonary edema be in heart failure (no pulmonary edema on CXR, JVP difficult to appreciate), but on CXR, JVP difficult to appreciate), but does have peripheral edema and SOB on does have peripheral edema and SOB on exertion (though confunded by COPD).exertion (though confunded by COPD).

Continue beta-blocker, ACE-i and Lasix as at Continue beta-blocker, ACE-i and Lasix as at homehome

Ischemia – no CP, first set of enzymes –ve.Ischemia – no CP, first set of enzymes –ve. Continue monitoring enzymes.Continue monitoring enzymes.


3)3) L leg painL leg pain The patient has difficulty walking due The patient has difficulty walking due

to his recent injury.to his recent injury.

PlanPlan TylenolTylenol or or PercocetPercocet for pain as needed for pain as needed PT consult to assist the patient with PT consult to assist the patient with

walking and rehabilitation from injurywalking and rehabilitation from injury


4)4) AnticoagulationAnticoagulation The patient is chronically on The patient is chronically on

Coumadin.Coumadin.

PlanPlan Continue Continue CoumadinCoumadin and monitor INR and monitor INR


5)5) COPDCOPD

PlanPlan AdvairAdvair BID nad BID nad AlbuterolAlbuterol PRN PRN

On further testingOn further testing

Carotid duplex US revealed mass in Carotid duplex US revealed mass in the neck on the left, recommended the neck on the left, recommended neck CTneck CT

Neck CT revealed neck mass Neck CT revealed neck mass compressing the internal carotid compressing the internal carotid artery.artery.

Neck vascular USNeck vascular US

Neck vascular USNeck vascular US Large hypoechoic lesionLarge hypoechoic lesion in the left carotid in the left carotid

space, space, displacing the internal jugular veindisplacing the internal jugular vein anteriorly anteriorly and the left common carotid and the left common carotid arteryartery posteriorly and medially. posteriorly and medially.

This lesion, due to its echogenicity may This lesion, due to its echogenicity may correspond to schwannoma, correspond to schwannoma, lipomalipoma, less , less likely muscle-derived tumor.likely muscle-derived tumor.

This lesion may compress several cranial This lesion may compress several cranial nerves, such as vagus or nerves, such as vagus or glossopharyngeal and may be the origin glossopharyngeal and may be the origin of the patient’s syncopal episode.of the patient’s syncopal episode.

Neck Neck CTCT

Neck CTNeck CT

Large Large lipomalipoma arising within the left carotid arising within the left carotid sheath, with mild sheath, with mild compression of the compression of the supraglottic larynxsupraglottic larynx and and marked compression marked compression of the left internal jugular veinof the left internal jugular vein..

Atherosclerotic diseaseAtherosclerotic disease with approximately with approximately 50% narrowing of the proximal 50% narrowing of the proximal left internal left internal carotid arterycarotid artery, and slightly less narrowing of , and slightly less narrowing of the proximal the proximal right internal carotid arteryright internal carotid artery. . There is also moderate focal narrowing of There is also moderate focal narrowing of the the right vertebral arteryright vertebral artery..

ConclusionsConclusions We believe that the patient’s syncope was We believe that the patient’s syncope was

due to reduced blood flow to the brain due to reduced blood flow to the brain caused by the contemporary presence of a caused by the contemporary presence of a large lipoma compressing the left common large lipoma compressing the left common and internal carotid arteries, and a moderate and internal carotid arteries, and a moderate atherosclerotic narrowing of the same vessel.atherosclerotic narrowing of the same vessel.

We asked for an ENT consult, which We asked for an ENT consult, which informed us about the difficulty of a surgical informed us about the difficulty of a surgical removal of the lipoma, due to its proximity to removal of the lipoma, due to its proximity to the larynx. Therefore, we suggested a the larynx. Therefore, we suggested a conservative managment and an ENT follow conservative managment and an ENT follow up.up.

an interesting case of syncope august 2005 white 10, team c – massachusetts general hospital,...

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