A 14-Year Old Boy with Sore Throat and Syncope

Abstract

Healio.com/Pediatrics | 403 Editor’s note: Each month, this department features a discussion of an unusual diagnosis. A description and images are presented, followed by the diagnosis and an explanation of how the diagnosis was determined. As always, your comments are welcome via email at Pediatrics@Healio.com. For diagnosis, see page 404 A14-year-old boy presented to the emergency department with a syncopal episode. The patient stated he was walking when he suddenly became flushed and diaphoretic. He experienced a witnessed loss of consciousness of 2 to 3 minutes without seizure-like activity or a post-ictal period. He had experienced a similar episode 2 years earlier when he had become dehydrated after being physically active for a prolonged period of time; he was told it was caused by heat exhaustion. The patient denied any history of alcohol or drug use, or family history of sudden cardiac death. On review of systems, the patient stated he had a sore throat for 2 days with intermittent chills, as well as decreased oral intake for 1 day. On examination, the patient’s vital signs included an oral temperature of 102.1°F, blood pressure of 124/69 mm Hg, heart rate of 122 beats per minute, respirations of 18 per minute, and room air oxygen saturation of 99%. The patient was a well-appearing adolescent male in no acute distress. His exam was significant for an exudative pharyngitis with anterior cervical lymphadenopathy, as well as a rapid regular heart rate with a prominent S2. An electrocardiogram (ECG) was performed upon arrival to the emergency department (see Figure 1). After receiving 500 mg ibuprofen, 500 mg penicillin VK for streptococcus pharyngitis, and a 500-mL normal saline bolus, the patient had a repeat ECG performed (see Figure 2, page 404). Six minutes later, he had a documented oral temperature of 99.2°F. The patient was transferred to a hospital with a pediatric cardiologist. The following morning, a repeat ECG was performed (see Figure 3, page 404), and an echocardiogram found no evidence of structural cardiac abnormalities. Case Challenge