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We report a patient with herpes simplex virus (HSV) encephalitis presenting as recurrent syncope due to sinus node arrest. Although the patient's initial presentation suggested a primary cardiac cause, an eventual diagnosis of HSV encephalitis was supported by computed tomography scan and magnetic resonance imaging, and confirmed by HSV polymerase chain reaction. The mechanism of cardiac arrhythmias in HSV encephalitis remains unclear; however, cardiac monitoring should be considered in all patients in whom the diagnosis is suspected. With diagnosis and appropriate management, a permanent pacemaker is generally not indicated. This case report highlights the importance of considering potentially reversible causes of collapse secondary to sinus node dysfunction beyond primary cardiac causes.
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PMID:Sinus node arrest secondary to HSV encephalitis. 1736 30

NTG (nitroglycerine) is used in routine tilt testing to elicit a vasovagal response. In the present study we hypothesized that with increasing age NTG triggers a more gradual BP (blood pressure) decline due to a diminished baroreflex-buffering capacity. The purpose of the present study was to examine the effect of NTG on baroreflex control of BP in patients with distinct age-related vasovagal collapse patterns. The study groups consisted of 29 patients (16-71 years old, 17 females) with clinically suspected VVS (vasovagal syncope) and a positive tilt test. Mean FAP (finger arterial pressure) was monitored continuously (Finapres). Left ventricular SV (stroke volume), CO (cardiac output) and SVR (systemic vascular resistance) were computed from the pressure pulsations (Modelflow). BRS (baroreflex sensitivity) was estimated in the time domain. In the first 3 min after NTG administration, BP was well-maintained in all patients. This implied an adequate arterial resistance response to compensate for steeper reductions in SV and CO with increasing age. HR (heart rate) increased and the BRS decreased after NTG administration. The rate of mean FAP fall leading to presyncope was inversely related to age (r=0.51, P=0.005). Accordingly, patients with a mean FAP fall >1.44 mmHg/s (median) were generally younger compared with patients with a slower mean FAP-fall (30+/-10 years compared with 51+/-17 years; P=0.001). The main determinant of the rate of BP fall on approach of presyncope was the rate of fall in HR (r=0.75, P<0.001). It was concluded that, in older patients, sublingual NTG provokes a more gradual BP decline compared with younger patients. This gradual decline cannot be ascribed to failure of the baroreflex-buffering capacity with increasing age. Age-related differences in the laboratory presentation of a vasovagal episode depend on the magnitude of the underlying bradycardic response.
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PMID:Impact of age on the vasovagal response provoked by sublingual nitroglycerine in routine tilt testing. 1750 42

Syncope and epileptic seizures have common presenting features that make it difficult to determine if a patient's collapse is primarily cardiac or neurologic. The distinction is blurred further if epileptic neural activity provokes cardiac arrhythmias known to cause syncope. We present a case of convulsive movements, progressive atrioventricular block, and syncope in a patient known to have epilepsy. The history, serial electrocardiographic tracings, and other diagnostic tests strongly suggest the ictal bradycardia syndrome. The case illustrates interesting aspects of central autonomic function and the diagnostic and therapeutic dilemmas of evaluating and treating patients who present with this problem.
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PMID:Syncope, seizure, or both? An unusual case of complete heart block. 1753 Dec 54

Cardiac tamponade, the accumulation of fluid in the pericardial space, leads to impaired venous return, loss of left ventricular preload, and hemodynamic collapse. The many causes of tamponade include malignancy, infection, inflammation, connective tissue disorders, and uremia. Herein, we report the case of a young woman who presented with syncope. She was found to have cardiac tamponade secondary to a chylous pericardial effusion that was due to a mature and benign anterior mediastinal cystic teratoma. Numerous reports have described pericardial effusions secondary to an anterior mediastinal cystic teratoma; however, to our knowledge, this is the 1st case of a teratoma causing chylopericardium that presented as tamponade.
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PMID:Chylopericardium presenting as cardiac tamponade secondary to an anterior mediastinal cystic teratoma. 1794 94

Sinus of Valsalva aneurysms are uncommon, especially those in the left sinus of Valsalva. A case of a 45-year-old woman with syncope is presented. She was in complete heart block. Auscultation revealed moderate aortic regurgitation. Transthoracic echocardiography revealed a subaortic membrane attached to the interventricular septum with expansion in diastole and collapse in systole. A diastolic flow was seen at the edge of this membrane. Transesophageal echocardiography revealed a cystic mass that was thought to be a large aneurysm with a parietal thrombus of the left coronary sinus extending into the interventricular septum. Magnetic resonance imaging confirmed the diagnosis. The aneurysm extension to the interventricular septum resulted in complete heart block, presumably through compression of normal atrioventricular nodal function. Case reports of the latter association are extremely rare. The present is a rare report describing the magnetic resonance imaging appearance of a left sinus of Valsalva aneurysm.
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PMID:A large aneurysm of a left sinus of Valsalva invading the interventricular septum--a rare cause of syncope. 1846 50

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a familial cardiac arrhythmia that is related to RYR2 or CASQ2 gene mutation. It occurs in patients with structurally normal heart and causes exercise-emotion-triggered syncope and sudden cardiac death. We experienced a case of CPVT in an 11 year-old female patient who was admitted for sudden cardiovascular collapse. The initial electrocardiogram (ECG) on emergency department revealed ventricular fibrillation. After multiple defibrillations, sinus rhythm was restored. However, recurrent ventricular fibrillation occurred during insertion of nasogastric tube without sedation in coronary care unit. On ECG monitoring, bidirectional ventricular tachycardia occurred with sinus tachycardia and then degenerated into ventricular fibrillation. To our knowledge, there has been no previous case report of CPVT triggered by sinus tachycardia in Korea. Therefore, we report the case as well as a review of the literature.
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PMID:A case of catecholaminergic polymorphic ventricular tachycardia. 1956 11

Pheochromocytomas are uncommon catecholamine-secreting tumors. The most common symptoms are of paroxysmal or sustained hypertension, or symptoms of paroxysmal adrenergic stimulation as palpitation, headache, and diaphoresis. The diversity of presentation often delays the diagnosis and is sometimes with catastrophic outcome. It had not been reported that acute myocardial infarction is a complication of ruptured pheochromocytoma. We describe a case with emergency department presented as acute myocardial infarction initially. On the following day, sudden drop of blood pressure and syncope attacked him. Coronary angiography revealed noncritical obstruction on proximal left anterior descending artery. After angioplasty, the patient still experienced episodes of hemodynamic collapse, and left flank pain developed. Abdominal computer tomogram demonstrated a large left adrenal tumor with fluid accumulation. Finally, the patient underwent surgical treatment and pathology confirmed the diagnosis.
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PMID:Ruptured pheochromocytoma presents as acute myocardial infarction. 1985 31

Anaphylaxis is a potentially life-threatening systemic allergic reaction, often with an explosive onset; the symptoms range from mild flushing to upper respiratory obstruction, with or without vascular collapse. Foods are common offending allergens and remain the leading cause of outpatient anaphylaxis in most surveys. Yacon (Smallanthus sonchifolius) is a plant native to the Andes region, where its root is cultivated and consumed mainly as food. Unlike most edible roots, yacon contains large amounts of ructooligosaccharides. Traditionally, yacon tubers have been used as a source of natural sweetener and syrup for people suffering from various disorders. We report the case of a 55-year-old woman who developed syncope and generalized urticaria after ingesting yacon roots. The patient had positive skin prick and intradermal tests to yacon extract. An open food challenge test was performed to confirm food anaphylaxis and was positive 10 minutes after the consumption of yacon roots. To our knowledge, this is the first reported case of anaphylaxis after the ingestion of yacon roots.
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PMID:A case of anaphylaxis after the ingestion of yacon. 2035 31

Acute pulmonary embolism (PE) presents as a constellation of clinical syndromes with a variety of prognostic implications. Patients with acute PE who have normal systemic arterial blood pressure and no evidence of right ventricular (RV) dysfunction have an excellent prognosis with therapeutic anticoagulation alone. Normotensive acute PE patients with evidence of RV dysfunction are categorized as having submassive PE and comprise a population at intermediate risk for adverse events and early mortality. Patients with massive PE present with syncope, systemic arterial hypotension, cardiogenic shock, or cardiac arrest and have the highest risk for short-term mortality and adverse events. The majority of deaths from acute PE are due to RV pressure overload and subsequent RV failure. The goal of fibrinolysis in acute PE is to rapidly reduce RV afterload and avert impending hemodynamic collapse and death. Although generally considered to be a life-saving intervention in massive PE, fibrinolysis remains controversial for submassive PE. Successful administration of fibrinolytic therapy requires weighing benefit versus risk. Major bleeding, in particular intracranial hemorrhage, is the most feared complication of fibrinolysis. Alternatives to fibrinolysis for acute PE, including surgical embolectomy, catheter-assisted embolectomy, and inferior vena cava (IVC) filter insertion, should be considered when contraindications exist or when patients have failed to respond to an initial trial of fibrinolytic therapy. Patients with massive and submassive PE may be best served by rapid triage to specialized centers with experience in the administration of fibrinolytic therapy and the capacity to offer alternative advanced therapies such as surgical and catheter-assisted embolectomy.
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PMID:Fibrinolysis for acute pulmonary embolism. 2092 1

Mounier-Kuhn syndrome is a rare condition that combines tracheobronchomegaly (TBM) and severe tracheobronchomalacia. Symptoms can be severe with recurrent bronchopulmonary infections and cough-induced syncope. Therapeutic management is non-specific and limited to chest physiotherapy and antibiotics during infectious exacerbations. We report a case of Mounier-Kuhn syndrome that was successfully managed by treating the posterior collapse of the central airway with yttrium aluminum pevroskyte laser. Endoscopic aspects, respiratory symptoms, and lung function tests all improved and remained stable with a follow-up of 8 years. Laser, at low power settings, could be a new therapeutic option in selected cases of tracheobronchomalacia.
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PMID:Endoscopic successful management of tracheobronchomalacia with laser: apropos of a Mounier-Kuhn syndrome. 2138 25


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