Syncopal Episodes Research Articles

Vestibular syncope: clinical characteristics and mechanism.

Background and ObjectivesVestibular syncope is a condition in which vertigo‐induced hemodynamic changes cause syncope. This study investigated the clinical and laboratory findings of vestibular syncope and tried to refine our knowledge of the mechanism underlying this newly recognized entity.MethodsThis study retrospectively analyzed 53 patients (33 women, median age = 63 years [interquartile range = 54–71 years]) with vestibular syncope from January 2017 to December 2021. To explain the mechanism of vestibular syncope, we incorporated a velocity‐storage model into the dual reflex pathways comprising the vestibulo‐sympathetic reflex and baroreflex and predicted the cardiovascular responses.ResultsTwenty (37.7%) patients had multiple episodes of vestibular syncope, and seven (13.2%) had potentially life‐threatening injuries. Meniere's disease (20.8%) and benign paroxysmal positional vertigo (9.4%) were the most common underlying vestibular disorders. Abnormal vestibular function tests included impaired cervical vestibular‐evoked myogenic potentials (57.5%) and positive head impulse tests (31.0%). Orthostatic hypotension was found in 19.5% of patients. Dyslipidemia (30.2%) and hypertension (28.3%) were common medical comorbidities. The dual reflex pathways incorporating the function of the velocity‐storage circuit in the brainstem and cerebellum suggest that vestibular syncope is a neurally mediated reflex syncope associated with a sudden hemodynamic change during vertigo. This change can be arterial hypertension triggered by a false downward inertial cue, as suggested previously, or hypotension driven by a false upward inertial cue.ConclusionsVestibular syncope is associated with various vestibular disorders and requires careful evaluation and intervention to prevent recurrent falls and significant injuries.

Brugada Syndrome: 30 Years of Scientific Adventure.

Thirty years ago, a distinct new clinical-electrocardiographic syndrome was described, now known as Brugada syndrome (BrS). Typical for this syndrome is EKG with ST elevation in the right precordial leads. The clinical presentation of the disease is highly variable: Patients may remain completely asymptomatic, but may also develop episodes of syncope, atrial fibrillation (AF), sick sinus syndrome (SSS), conduction disturbances, asystole, and ventricular fibrillation (VF). The disease is caused by mutations in the genes responsible for the action potential of the heart cells. The most frequently involved gene is the SCN5A which controls the structure and function of the cardiac sodium channel. Describing this new syndrome has had very positive implications in all fields of medicine.

Gasping for Air, Pancakes, and Tears

Shortly before the emergence of coronavirus disease 2019 (COVID-19), my mother had a syncopal episode, breaking her hip. After 2 failed hip pinnings, she had total hip arthroplasty. She was a very youthful 85 with few health problems; yet, in the recovery room, they were unable to wean her off oxygen. We were in the emergency room 3 times to rule out a pulmonary embolus. Whatever diagnosis you are coming up with in your mind, trust me, we went there. Her team of amazing pulmonologists, each with a specialty in the recesses of pulmonary medicine, were baffled.

Shy-Dragger Syndrome – An underdiagnosed sad reality?

Multiple System Atrophy (MSA) regards a group of neurodegenerative diseases sharing the same physiopathology. It is a rare group of diseases and often represents a diagnostic challenge for clinicians. Mild symptoms are present at the onset of the disease and are often neglected by patients. The case report describes a 62-year-old female with multiple episodes of syncope with 3 months evolutions. Anamnesis revealed sleep apnoea and urinary incontinence. In order to perform complementary exams, the patient was admitted to the medical ward. Autoimunnity results were negative discarding this etiology; 24-hour arterial pressure monitoring revealed a severe fluctuation of tensional values capable of explaining syncope. Other exams revealed no pathological alterations responsible for the patient complaints. Multiple System Atrophy diagnosis was made after exclusion of other possible aetiological causes for the patient’s symptoms. More prevalent diseases such as Parkinson’s Disease, atypical Parkinsonic syndromes, and pure autonomic failure, among others may replicate the same symptoms. Diagnosing the patient with Multiple System Atrophy represented a challenge because of its rarity and clinical complexity. Being a disease with poor outcomes and representing necessary lifestyle changes to the patients and family life, an early and exact diagnosis may provide time and more life quality, within the disease limitations. Internists are often presented with complex patients being obligated to gather all pieces, and put them together, so that de puzzle may be deciphered. Learning points - Multiple systems atrophy is a rare incapacitating disease and it is believed to be underdiagnosed; - Complex diseases often present mild nonlimiting symptoms that patients might tend to neglect.

Etiology and Age Distribution of Syncope in Delta Area Patients

Background: Syncope is a Total Loss of Consciousness (TLOC) due to cerebral hypo-perfusion, characterized by a rapid onset, short duration, and spontaneous complete recovery. It shares many clinical features with other disorders; it therefore presents in many differential diagnoses. This group of disorders is labelled TLOC. The aim of the present study was to determine the etiologies and the age distribution of patients with syncope in Delta area.
 Methods: This study included thirty patients who had at least one episode of syncope. All patients in this study were subjected to history taking, clinical examination, laboratory investigations, standard 12-lead Electrocardiogram (ECG), Resting Transthoracic Echocardiography (TTE). Some patients were subjected to Prolonged ECG monitoring (Holter, Event, ILR), Brain computed tomography (CT) and Magnetic resonance imaging (MRI), Tilt table test and Electrophysiology study (EP study).
 Results: Most common ECG rhythm was normal sinus rhythm, complete heart block, left ventricular hypertrophy, Slow Atrial fibrillation (AF), Left bundle branch block (LBBB), ventricular tachycardia. The most common diagnosis of syncope was vasovagal syncope, idiopathic syncope then cardiac syncope. Incidence of idiopathic syncope in populations under 40 years was significantly higher than in populations over 40 years, meanwhile regarding cardiac-related etiology for syncope in patients under age 40 was significantly lower than those patients over age 40.
 Conclusion: For age distribution, the incidence of idiopathic syncope in populations under 40 years was significantly higher than in populations over 40 years, meanwhile cardiac-related etiology for syncope in patients under age 40 was significantly lower than those patients over age 40.

What next and what to expect?

What next and what to expect? A 17-year-old female presented with painless progressive loss of vision in both eyes (OU) with multiple episodes of syncope and postural giddiness for 1 month. On ocular examination, best-corrected visual acuity (BCVA) was 1/60 in the right eye (OD) and finger counting close to the face in the left eye (OS); intraocular pressure was within normal limits in both the eyes. Slit-lamp examination revealed corkscrew conjunctival vessels [Fig. 1a), anterior chamber (AC) cells 1(+), and iris neovascularization. Pupils were mid-dilated and sluggishly reacting to light. Fundus examination revealed hyperemia and neovascularization of the disc, dilated retinal veins with a beaded appearance, patches of retinal whitening over the macula and peripapillary area, and arterio-venous (AV) anastomosis [Fig. 1b and 1c]. What is the Next Step? Systemic examination Computed tomography (CT)-angiography Fundus fluorescein angiography and optical coherence tomography All of the above Findings On systemic examination, the radial artery pulse could not be felt, and the carotid pulsations were felt very feebly on both sides. The pulse rate measured in the right popliteal artery was 80/min. Blood pressure (BP) was not recordable in the upper limbs. BP recorded in the right lower leg was 150/90 mm Hg. CT angiography revealed severe luminal narrowing involving the left common carotid artery and left subclavian artery at the ostial level, and juxta-ostial narrowing of the right brachiocephalic trunk with multiple enhancing collateral channels noted in the neck [Fig. 1d-f].Figure 1: (a) Slit-lamp photography showing corkscrew conjunctival vessels, (b) and (c) fundus images showing neovascularization of the disc, dilated retinal veins with beaded appearance, patches of retinal whitening over the macula and peripapillary area, and arterio-venous anastomosis, computed tomography (CT) angiography image showing (d) narrowing of the right brachiocephalic trunk (yellow arrow), (e) narrowing of the left common carotid artery (yellow arrow), (f) stenosed left subclavian artery, minimal contrast filled vessel seen (yellow arrow)Proliferative retinopathy in both eyes was treated with pan-retinal photocoagulation (PRP) and one intravitreal injection of bevacizumab (Avastin) in OS. She received oral prednisolone for the systemic condition. Subsequently, she underwent phacoemulsification with foldable intraocular lens implantation in OU. She had a BCVA of 20/120 in OD and 20/400 in OS at the last follow-up visit. Diagnosis: Takayasu arteritis (TA) with Takayasu retinopathy Correct Answer: B Discussion TA is a chronic inflammatory disease affecting the large and medium-sized vessels, predominantly in the aorta and its main branches leading to the arterial wall thickening, fibrosis, stenosis, and thrombus formation resulting in cerebral and ocular ischemia.[1] Ophthalmic features in TA result from either due to the obliteration of arteries causing ischemic ocular changes (hypotensive retinopathy) or due to renal artery stenosis causing uncontrolled hypertension (hypertensive retinopathy).[2] Manifestations due to retinal hypoxia are microaneurysms, AV anastomosis, retinal vein occlusion, proliferative retinopathy, cataract, neovascular glaucoma, ocular ischemic syndrome, ischemic optic neuropathy, optic atrophy, retinal detachment, etc.[3] Statement of ethics Written informed consent for publication (including the images) has been obtained from the parent of the patient. All procedures carried out were in accordance with the tenets of the Declaration of Helsinki. Institute Ethics Committee approval is not required for a case report according to Indian council of medical research guidelines. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

591 Abdominal Apoplexy – a Case of Spontaneous Haemoperitoneum from Pancreaticoduodenal Artery Bleed

Abstract Background Inferior pancreaticoduodenal artery (IPDA) haemorrhages are extremely rare and often occur secondary to IPDA aneurysms. They can result in a spontaneous life-threatening bleed which requires urgent treatment via transcatheter arterial embolisation (TAE). Case Summary We report the case of an IPDA haemorrhage in a 52-year-old male who presented with a one-day history of severe worsening generalised abdominal pain. Although his initial blood pressure, heart rate and haemoglobin were within the normal range, he had a persistent metabolic acidosis with raised lactate. This prompted an urgent out-of-hours Computed Tomography (CT) scan. On return to the ward, he had a syncopal episode and was found to be in shock. An urgent venous blood gas revealed a substantial haemoglobin drop (133g/L to 88g/L) and review of his imaging identified intra-abdominal haemorrhage, confirmed by radiology to be an IPDA haemorrhage. The patient was managed according to the trust's major haemorrhage protocol and blue light transfer to a tertiary centre for embolisation by interventional radiology was arranged. He was transferred with ongoing resuscitation, and successfully underwent TAE of the IPDA. No aneurysm or other pathology was noted on angiography. Conclusion IPDA haemorrhages are uncommon. Physiological compensation may normalise initial observations and initial haemoglobin level may also be falsely reassuring. Therefore, it is important to monitor physiological indicators, such as pH and lactate, as real-time severity indicators to identify emergency pathology early.

Successful ablation of a wide complex tachycardia with distinct intracardiac electrograms.

A 13-year-old boy was hospitalized after a syncopal episode that occurred during exercise. He suddenly felt chest tightness, sweating and palpitations, followed by a transient loss of consciousness. Upon emergency medical team arrival, he was awake and oriented. Baseline ECG showed sinus rhythm at a rate of 98 bpm, with narrow QRS, and no signs of long QT, Brugada, or pre-excitation. Physical examination, blood tests, 24 hours Holter monitoring, transthoracic echocardiography and stress test were all within normal limits. Eight days later he experienced a second episode of palpitations while walking to school. ECG revealed regular wide complex tachycardia (WCT) at a rate of 200 bpm, with LBBB morphology that terminated with Adenosine (Figure 1). The clinical tachycardia was easily induced by programmed electrical stimulation (Figure 2A). Diagnostic electrophysiological maneuver (Figure 2B) was followed by successful ablation, during which a unique phenomenon was noted (Figure 3). What is the diagnosis of the tachycardia and what are the unique findings noted during and after ablation? This article is protected by copyright. All rights reserved.

Genetic Analysis of Cardiac Syncope-Related Genes in Korean Patients with Recurrent Neurally Mediated Syncope.

Neurally mediated syncope (NMS) is a common clinical problem. The underlying genetic factors of NMS remain controversial. We hypothesized that cardiac syncope-related genes may contribute to NMS in patients with previous frequent syncopal episodes and/or a family history of syncope. A total of 54 consecutive patients diagnosed with NMS were prospectively enrolled between 2013 and 2016. Inclusion criteria were more than five syncopal episodes with a family history of syncope (n = 17) or more than five syncopal episodes with no family history of syncope (n = 37). Ninety-eight cardiac syncope-related genes (channelopathy: 43 genes, cardiomyopathy: 50 genes, primary pulmonary hypertension: 5 genes) were screened by exome sequencing. All identified variants were classified according to the standards and guidelines by the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Of the 54 patients, 17 patients (31.5%) had a family history of syncope. Two patients (3.7%) had pathogenic and likely pathogenic variants (PV/LPV) in cardiac syncope-related genes TTN and MYH7. We investigated genetic variation in patients with frequent NMS with a positive family history of syncope in Korea. PV/LPVs in genes related to cardiomyopathy were associated with recurrent NMS in Korean patients. Closer follow-up of these patients might be needed.

In Vitro Drug Screening Using iPSC-Derived Cardiomyocytes of a Long QT-Syndrome Patient Carrying KCNQ1 & TRPM4 Dual Mutation: An Experimental Personalized Treatment.

Congenital long QT syndrome is a type of inherited cardiovascular disorder characterized by prolonged QT interval. Patient often suffer from syncopal episodes, electrocardiographic abnormalities and life-threatening arrhythmia. Given the complexity of the root cause of the disease, a combination of clinical diagnosis and drug screening using patient-derived cardiomyocytes represents a more effective way to identify potential cures. We identified a long QT syndrome patient carrying a heterozygous KCNQ1 c.656G>A mutation and a heterozygous TRPM4 c.479C>T mutation. Implantation of implantable cardioverter defibrillator in combination with conventional medication demonstrated limited success in ameliorating long-QT-syndrome-related symptoms. Frequent defibrillator discharge also caused deterioration of patient quality of life. Aiming to identify better therapeutic agents and treatment strategy, we established a patient-specific iPSC line carrying the dual mutations and differentiated these patient-specific iPSCs into cardiomyocytes. We discovered that both verapamil and lidocaine substantially shortened the QT interval of the long QT syndrome patient-specific cardiomyocytes. Verapamil treatment was successful in reducing defibrillator discharge frequency of the KCNQ1/TRPM4 dual mutation patient. These results suggested that verapamil and lidocaine could be alternative therapeutic agents for long QT syndrome patients that do not respond well to conventional treatments. In conclusion, our approach indicated the usefulness of the in vitro disease model based on patient-specific iPSCs in identifying pharmacological mechanisms and drug screening. The long QT patient-specific iPSC line carrying KCNQ1/TRPM4 dual mutations also represents a tool for further understanding long QT syndrome pathogenesis.

Feasibility of Blood Pressure Measurement With a Wearable (Watch-Type) Monitor During Impending Syncopal Episodes.

BackgroundWe assessed the reliability and feasibility of blood pressure (BP) measurements by means of a new wearable watch‐type BP monitor (HeartGuide) in detecting episodes of hypotensive (pre)syncope induced by tilt table test.Methods and ResultsAn intrapatient comparison between systolic BP (SBP) measured by means of the HeartGuide device and noninvasive finger beat‐to‐beat BP monitoring was undertaken both at baseline in supine position and repeatedly during tilt table test in patients evaluated for reflex syncope. Intrapatient fall of systolic BP from baseline was measured. Eighty‐one patients (mean age, 61±19 years; 46 women) were included. Overall, HeartGuide was able to yield BP values at the time of BP nadir in 58 (72%) patients (average HeartGuide SBP 102±18 mm Hg, versus finger SBP 101±19 mm Hg). Compared with baseline, the maximum SBP decrease was on average −28.5±27.8 and −30.3±33.9 mm Hg respectively (Lin's concordance correlation coefficient=0.78, r=0.79, P=0.001). In the subgroup of 38 patients with tilt table test induced (pre)syncope, the average HeartGuide SBP during symptoms was 97±16 mm Hg, and the finger SBP was 94±18 mm Hg. Compared with baseline, the maximum SBP decrease was on average −35.2±29.3 and −43.3±31.8 mm Hg, respectively (Lin's concordance correlation coefficient=0.83, r=0.87, P=0.001).ConclusionsOur data indicate that the HeartGuide BP monitor can detect low BP during presyncope and that its measure of SBP change is consistent with that simultaneously obtained through continuous BP monitoring, despite some intrapatient variability. Thus, this device might be useful in determining the hypotensive nature of spontaneous (pre)syncopal symptoms, a possibility that should be verified by field studies.

“Blocked broken heart syndrome”: an unusual case of a complete atrioventricular block complicating a Takotsubo cardiomyopathy

BackgroundComplete heart block is considered a unique and rare complication of Takotsubo cardiomyopathy, an otherwise self-resolving disease. When this occurs, there is a double clinical dilemma: first to find out which triggered the other and second, to decide whether or not to implant a permanent pacemaker.Case presentationWe present a case of a 77 years-old female patient, with previous medical history of arterial hypertension, diabetes mellitus, dyslipidemia and bifascicular block known since 2013. She came to the emergency department after recurrent syncopal episodes. At admission a complete heart block was diagnosed, and it was implanted a single chamber temporary pacemaker. The patient remained in disproportional acute decompensated heart failure despite pacemaker implantation. She denied chest pain although referring an episode of self-limiting chest pain 2 days before, after an argument with the family. Blood analysis showed an important rise in NTproBNP and troponin levels. Transthoracic echocardiogram showed a dilated left ventricle with akinesia of apical and mid segments, hyperkinesia of basal segments and severely depressed left ventricle ejection fraction. Coronary angiography showed no significant lesions and the diagnosis of Takotsubo cardiomyopathy was suspected. During the following days, she recovered her own intrinsic rhythm. Electrocardiogram evolved with deep T-wave inversion and prolonged QT interval and transthoracic echocardiogram showed resolution of the previous alterations. Despite complete reversion of rhythm alteration, it was decided to implant a permanent pacemaker.ConclusionsWe describe a rare, life-threatening and often underdiagnosed complication of the stress cardiomyopathy. Furthermore, we performed a literature revision of this rare complication and discussed the therapeutic challenge encountered in such patients.

Trancatheter Aortic Valve Implantation in the Treatment of Heyde's Syndrome: A Case Report

Calcified aortic stenosis is the most common valvulopathy of the elderly. Its association with angiodysplasia and digestive bleeding is known as Heyde syndrome. This clinical case highlights the importance of the diagnosis of this syndrome whose complications can be fatal. The cessation of gastrointestinal bleeding is often remarkable after aortic valve replacement. Transcatheter aortic valve implantation (TAVI) can represents a good alternative to surgical valve replacement, especially in patients with high surgical risk. We report a case of 62-year-old patient, admitted for management of global cardiac decompensation on a tight aortic stenosis, confirmed by transthoracic echocardiography as well as a few episodes of syncope. He had a history of repeated lower digestive hemorrhages that required several transfusions. The evolution was marked by the appearance of heavy rectal bleeding on cecum angiodysplasia lesions confirmed by colonoscopy. The association of digestive bleeding and aortic stenosis raised the diagnosis of Heyde syndrome. An assay of von Willebrand factor (vWF) antigen, vWF binding collagen activity and their ratio confirmed a qualitative deficiency of vWF type 2A. The proposed treatment was TAVI because of the high surgical risk and the patient's refusal of the surgery. The evolution at 1 month post TAVI was marked by the improvement of hemostatic parameters related to the vWF and the disappearance of cardiac symptomatology. The cessation of gastrointestinal bleeding in Heyde's syndrome is conditioned by percutaneous aortic valve replacement in the high-risk surgical subject with a good clinical and biological evolution.

Procedural Characteristics, Safety, and Follow-up of Modified Right-Sided Approach for Cardioneuroablation

Background: Cardioneuroablation is one of the emerging therapies in vasovagal syncope. In this study, we present a simple method of cardioneuroablation performed via a right-sided approach, targeting anterior-right and right-inferior ganglionated plexi, along with procedural and follow-up data.Methods: Patients who had underwent cardioneuroablation between March 2018 and September 2019 with vasovagal syncope in 2 clinics were enrolled in the study. All patients underwent radio-anatomically guided radiofrequency ablation targeting anterior-right ganglionated plexi and right-inferior ganglionated plexi. Syncope and symptom burden, 24-hour ambulatory electrocardiogram data at presentation, and at follow-up were assessed along with procedural data.Results: A total of 23 patients underwent modified right-sided cardioneuroablation. Mean basal cycle length decreased significantly from 862.3 ± 174.5 ms at the beginning of the procedure 695.8 ± 152.1 ms following the final radiofrequency ablation (P < .001). Mean 24-hour ambulatory heart rate increased significantly from 66.4 ± 10.7 bpm at baseline to 80 ± 7.6 bpm at follow-up (P < .001). Only 1 patient had 1 episode of syncope following the procedure at the mean follow-up period of 10 ± 2.9 months. The same patient had recurrent presyncope. Conclusion: The right-sided cardioneuroablation approach was found to be an effective treatment for vasovagal syncope and may be regarded as a default initial cardioneuroablation technique.

EnSite NavX mapping system guided implantation of a dual-chamber permanent pacemaker in a 41-year-old pregnant woman with a 4-year follow-up

BackgroundX-ray fluoroscopy has been the primary cardiac imaging modality in permanent pacemaker implantation (PPI) operations, but it inevitably results in radiation exposure for both operators and patients. Fluoroscopy is considered a contraindication, especially in certain circumstances, such as gestation, during which the fetus is most sensitive to radiation exposure. Therefore, measures to avoid radiation exposure are necessary, and a more safe and feasible approach is needed for this procedure. Since the EnSite NavX mapping system (ENMS) can create the required geometric contours of those relevant cardiac structures and chambers, it can be used as an alternative to X-ray fluoroscopy in PPI. In addition, because the displacement of atrial leads is a common complication of PPI, lead displacement may occur more readily without fluoroscopic guidance. Therefore, reliable measures are required to prevent leads from displacement.Case introductionA 41-year-old woman at the 15th week of gestation was referred to our department with recurrent episodes of syncope and amaurosis fugax for 2 years. Holter monitoring showed sinus rhythm, Mobitz Type II atrioventricular block and high-grade atrioventricular block with ventricular arrest up to 4945 ms. A dual-chamber PPI was performed successfully for the patient under the guidance of the ENMS instead of fluoroscopy. Displacement of atrial lead was effectively avoided by bending the top of atrial lead before implantation and making it a U-shape during operation, which left space for possible subsequent external pulling stress.ConclusionsFor PPI, ENMS is a feasible and reliable alternative to traditional X-ray fluoroscopy, especially when performing operations on pregnant patients. By bending the top of the active-fixation atrial lead into a U-shape during operation, the displacement of atrial lead may be avoided.

Orbitomalar Erosive Basal Cell Carcinoma.

A 75-year-old Caucasian, immune-competent, and otherwise healthy male presented to the emergency department after a syncopal episode. He had a secondary complaint of left facial disfigurement and OS vision loss over the past few years. He reported this began as small “red nasal growth” 5 years ago. The lesion progressively grew and then became erosive; despite significant facial destruction, he did not seek medical care because of personal reasons. On exam, best corrected visual acuity was 20/40 in the OD and light perception in the OS. The right pupil and extraocular movements were within normal limits. He had left cicatricial hypotropia with diffusely restricted extraocular motility. Exam demonstrated erosion and absence of left midfacial soft tissues and bone including the orbital floor and anterior nasomaxillary area. The cornea was opaque with a chronic ulcer with temporal scleral thinning and uveal exposure (Fig. 1 and 2). Written consent was obtained for photography.FIG. 1.: External photograph demonstrating erosive changes of the orbit, maxillary sinus, nose, and face secondary to basal cell carcinoma.FIG. 2.: External photograph demonstrating corneal opacification, temporal scleral thinning and uveal exposure of the globe secondary to erosive basal cell carcinoma of the face.His syncopal episode was determined to be due to bacterial sepsis secondary to the facial infection. Pseudomonas aeruginosa and methicillin sensitive Staphylococcus aureus were isolated on facial wound culture. Treatment with broad spectrum antibiotics was initiated. Biopsies revealed ulcerated basal cell carcinoma (nodular type). CT imaging revealed no metastatic disease. Medical oncologic management was recommended for this nonresectable, advanced, facial-erosive disease. Eye removal surgery is contemplated for infectious disease control, but he currently has no significant pain. This case demonstrates the devastating oculofacial effects of neglected basal cell carcinoma.

Approach to Pancytopenia in a Deployed Service Member

Pancytopenia is a result of increased destruction or decreased production of bone marrow cells and has a broad differential. Pernicious anemia commonly presents as a macrocytic anemia and is typically autoimmune in nature and the result of vitamin B12 deficiency. Pancytopenia is a rare presentation of this disorder especially in the setting of hemolysis. Testing in the deployed setting may be limited and/or challenging. A 24-year-old female patient with a history of Hashimoto thyroiditis presented during an overseas deployment with a witnessed syncopal episode and was found to be pancytopenic with a mild transaminitis and laboratory tests demonstrating hemolysis. Though initially she was hypotensive, tachycardic, and febrile, her vitals improved after multiple transfusions, but she had persistent cytopenia with transfusion dependence, concerning for aplastic anemia or acute leukemia. Testing for B12 deficiency is crucial in symptomatic, patients with pancytopenic to either diagnose or exclude pernicious anemia and conserve resources by preventing costly workup and transfer/escalation of medical care, especially in the deployed setting. A predeployment screening in those with history of autoimmune disorders may be warranted.

Congenital Anomalous Origin of Coronary Artery Disease in Children With Syncope: A Case Series.

ObjectiveThis study is aimed to analyze the characteristics of congenital anomalous origin of coronary artery in pediatric patients with syncope.MethodsA total of eight patients were retrospectively analyzed from August 2018 to August 2020 who were admitted to the Peking University First Hospital with the complaint of syncope and were diagnosed with congenital coronary artery disease.ResultsIn total, eight patients were included in the study with a median age of 12.5 ± 2.7 (8–16) years. In total, four of them were males, and four were females. Six of the eight patients were diagnosed with right anomalous coronary artery from the opposite sinus (R-ACAOS), while two patients were diagnosed with left anomalous coronary artery from the opposite sinus (L-ACAOS). The most frequent inducement was exercise, and the commonest prodromes were dizziness and blurred vision. Serum cardiac markers and exercise electrocardiography test (EET) were normal in seven of the patients. The majority of cases had abnormal electrocardiograms (ECGs), but only two of them manifested elevated/depressed ST-T segments. In total, seven patients had positive head-up tilt test (HUT). Echocardiography and coronary artery computed tomography angiography (CTA) were performed to aid the diagnosis. Coronary unroofing procedures were conducted in four patients, and none of them reported syncope after the surgery. The other four patients received routine medical treatment for vasovagal-like syncope. In total, two patients out of them became asymptomatic, and in the other two patients, episodes of syncope were reduced, but they still required medical treatment.ConclusionCongenital coronary artery anomalies in children with syncope need prompt attention. Though ECG and echocardiography are the common methods for investigating cardiac syncope, they have limited ability to find coronary artery anomalies. When coronary artery anomalies are suspected, coronary CTA should be considered.

Permanent Pacemaker Insertion in a Patient with Persistent Left Superior Vena Cava

Implantation of a permanent pacemaker (PPM) in a patient with venous anomalies can be quite difficult, especially in a patient with persistent left superior vena cava (PLSVC). Our patient was a 63-year-old female who presented with complaints of dizziness and an episode of syncope. Her electrocardiogram was suggestive of a complete heart block. We approached the right side of the heart through the right infraclavicular cephalic vein initially, as that is the preferred site in our hospital. We encountered difficulty negotiating the leads through the right side, which raised the possibility of PLSVC. We report the various steps we took while inserting the PPM in this case.

Temper Tantrums and Breath-Holding Spells

Temper Tantrums and Breath-Holding Spells