Case 2: An unusual cause of syncope

Abstract

An 11-year-old girl presented to the emergency department with three brief episodes of syncope that day. Before each episode, the patient was standing and then felt weak and dizzy. Subsequently, she vomited once and experienced lower abdominal pain. She had no fever, diarrhea or dysuria. She denied visual or gait disturbances, weakness, paresthesia, chest pain or shortness of breath. There was a remote history of trauma one month previous when she fell approximately four feet off an unloading ski chairlift onto her abdomen. She was examined and medically cleared at the time. Her past medical history was unremarkable. Her menarche was one month earlier, and she denied being sexually active. She was on no medications. On physical examination in the emergency department, she appeared pale with slightly dry mucus membranes. She was alert with a supple neck. Her heart rate was 120 beats/min and her respiratory rate was 20 breaths/min. Her blood pressure was 110/60 mmHg and she was saturating 98% in room air. When she sat up, she felt dizzy and presyncopal. Her head and neck examination was normal. Her cardiorespiratory examination revealed a clear chest with no murmurs and normal peripheral pulses and perfusion. Her abdomen was soft with diffuse tenderness in the lower quadrants bilaterally. Her neurological examination was normal. Initial investigations revealed a white blood cell count of 14.3 × 109/L, hemoglobin of 101 g/L, and platelets of 274 × 109/L. The urine pregnancy test was negative. Liver function tests, renal function tests and amylase were normal. The chest x-ray and electrocardiogram were within normal limits. The patient was given a bolus of 20 mL/kg of normal saline and sent for an abdominal CT (computed tomography) scan where the diagnosis was made. When the hemoglobin was repeated 4 h later because of the CT scan findings, it had dropped to 81 g/L.