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Cough Making Ground for Syncope: A Case Report FREE TO VIEW

Komaldeep Kaur, MD; Amrit Pal Kansal, MD; Gopal Chawla, MD; Naresh Kumar, MD
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Pulmonary Medicine, Government Medical College, Patiala, New Delhi, India

Chest. 2014;146(4_MeetingAbstracts):422A. doi:10.1378/chest.1988569
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SESSION TITLE: Miscellaneous Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Syncope is defined as a transient loss of consciousness with subsequent spontaneous recovery, resulting from global cerebral hypoperfusion. Cough syncope was first described by J.-M. Charcot (1825-1893) in 1879 as “laryngeal vertigo” Cough syncope refers to syncope upon coughing, the pathogenesis of which is unclear and probably multi-factorial. Cough syncope is a well-recognized but uncommon phenomenon. We present a case of 34yrs obese male having cough as a cause for his syncope.

CASE PRESENTATION: A 34 years-old male presented with a 2 weeks history of multiple episodes where he lost consciousness during or after cough. The syncopal events lasted for durations ranging from 30 seconds to about one minute. All this was disturbing his routine life at home and at workplace. . There was history of brief jerky movements of body during the episode but no history of incontinence or tongue biting. He was not on any medication in the past. Chest x-ray and pulmonary function tests were normal.He initially presented with these symptoms to another facility where a 2D-ECHO was performed which was suggesting nothing more than mild concentric left ventricular hypertrophy with EF of 60%. He was transferred to our hospital for further evaluation. He was a chronic alcoholic. His weight was 97kgs and BMI was 32.4. During his hospital stay, many witnessed episodes of cough-induced syncope occurred. During an episode, his systolic blood pressure showed a reduction from 110 mmHg to 80 mmHg. His face became congested and he lost his conscious. The blood pressure returned to baseline as soon as the symptoms resolved. CECT chest was normal except for an incidental finding of osteochondroma of 3rd and 4th right thoracic ribs. Symptomatic management of patient was done with cough suppressants and bronchodilators. Dietary and life style modification was advised to the patient. He was discharged a few days later for outpatient follow-up and is having no more syncopal attacks

DISCUSSION: Syncope is a loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset , short duration, and spontaneous complete recovery. Cough syncope is classified as situational syncope. Situational syncope traditionally refers to reflex syncope (neurally-mediated) associated with some specific circumstances (micturition, cough, defecation, swallowing). Intrathoracic pressure increases during cough and obstructs the venous outflow, which leads to an acute decrease of heart output and blood pressure.4-6 As a consequence of the above mechanisms, the decrease of cerebral perfusion results in loss of consciousness Recurrent syncope has serious effects on the quality of life as was seen in our patient. Majority of cough syncope was reported in male, middle-aged, overweight and chronic bronchitic smokers. Cough syncope may result with serious problems such as traffic accidents, falls leading to brain and extremity injuries. Physicians should be aware of this easily recognizable cough induced syncope in all subjects admitted with syncope and should screen possible underlying sources of cough.

CONCLUSIONS: The differential diagnosis of cough syncope includes epilepsy and cataplexy. Cough syncope may present with clonic movements during the syncopal episode which might be confused with epilepsy. Careful history is needed to differentiate these two conditions as cough syncope always occurs with a coughing episode. The onset of symptoms in cough syncope is usually at an older age and patients deny any postictal confusion, tongue bite, bladder or bowel incontinence. Cough syncope tends to improve with treatment of underlying pulmonary dysfunction

Reference #1: Kapoor WN: Evaluation and management of the patient with Syncope.JAMA 1992, 268(18):2553 2560

Reference #2: McIntosh HD, Estes EH, Warren JV. The mechanism of cough syncope. Am Heart J. 1956 Jul;52(1):70-82

DISCLOSURE: The following authors have nothing to disclose: Komaldeep Kaur, Amrit Pal Kansal, Gopal Chawla, Naresh Kumar

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