Her other medical history included bronchial asthma well controlled with medical treatment, ischemic heart disease, hypercholesterolemia, hypertension, hypothyroidism, and heavy smoking. Her current medications included bisoprolol, valsartan, aspirin, clopidogrel, rosuvastatin, levothyroxine, Montelukast, and budesonide by inhalation. Lungs examination revealed prolonged experium with expiratory wheezing. In the department, a few attacks of cough syncope were observed while the patient was on continuous monitoring of ECG, blood pressure, and oxygen saturation.
No significant changes in heart rate and blood pressure were observed during these episodes. The patient was treated orally with azithromycin for 5 days, inhalation of budesonide and salbutamol, prednisone and her other previous medications. A gradual significant clinical improvement occurred with decline in the intensity and frequency of the coughing episodes until complete resolution of these episodes 1 week later, and termination of the syncopal attacks with termination of azithromycin treatment.
No violent episodes of coughing or syncope occurred during a follow-up period of 4 months. Syncope is a transient self-limited loss of consciousness due to acute global impairment of cerebral blood flow. The onset is rapid, duration is brief, and recovery is often spontaneous and complete.
In cough syncope, loss of consciousness usually occurs immediately after a cough, and more commonly after prolonged bouts of violent coughing, lasting for seconds with rapid restoration of full consciousness. It more commonly occurs in middle-aged, obese smoker males with obstructive lung disease [ ]. Until yet, more than cases of cough syncope have been reported in the medical literature [ 1 , ].
This syndrome could be accompanied with significant increase of morbidity and mortality as with any syncope. Numerous motor vehicle accidents resulting from cough syncope have been reported. These reports include the death of two drivers and three pedestrians [ 1 ]. It seems likely that the real number of deaths due to cough syncope-related motor vehicle accidents is much more than is reported, particularly if it caused death of the driver, since in this case nobody can know what the cause of the accident was.
The precise pathophysiologic mechanism of cough syncope is not fully understood, and remains a matter of debate [ ]. Several mechanisms have been proposed in this regard. With continuous coughing, intra-thoracic pressure increases resulting in decrease in venous return, ventricular filling, cardiac output, and blood pressure [ 15 ]. Since cough syncope may occur without prolonged period of coughing, it has been suggested that baroreceptor mechanism via a baroreceptor-initiated neural vasodilation-bradycardia reflex, further reducing blood pressure, could be partly responsible for the syncope.
Hence, subjects susceptible for cough syncope exhibit greater hypotensive response to transient exaggerated intra-arterial pressure pulses. Both the magnitude and duration of the consequent hypotension are greater than in other fainters, and the hypotensive-triggered compensatory positive chronotropic response is absent or markedly suppressed [ 14 , 15 ].
Other suggested mechanisms indicates that the increased intra-thoracic pressure during coughing is transmitted to the cerebrospinal fluid, causing an acute pressure increase in the skull, compromising cerebral perfusion and resulting in syncope [ 16 , 21 ].
Complete atrioventricular block in patients with left bundle branch block [ 19 ], carotid sinus hypersensitivity [ 20 ], sinus arrest in patients with sick sinus [ 22 ], and synergistic effect between jugular venous reflex and plasma endothelin-1 levels [ 23 ] have also been suggested.
Simultaneous occurrence of multiple pathophysiological processes may be required to induce cough syncope [ 1 ]. In our three patients, no significant decrease in blood pressure or heart rate was observed during their syncopal attacks, suggesting that decrease in cerebral perfusion due to increased intra-thoracic pressure seems the likely mechanism for their syncope. In the third patient, decrease of oxygen saturation during her violent coughing may partly participate in the development of cough syncope.
Pertussis continues to be an important public-health issue. Despite widespread vaccination, Bordetella pertussis is increasingly identified as a cause of sub-acute and chronic cough in adolescents and adults. The clinical characteristics of pertussis among adults are less obvious than among children. While the clinical presentation in children classically consists of three phases catarrhal, paroxysmal and convalescent [ 24 ], in adults it is usually a long and mild disease, and may show atypical manifestations with prolonged cough [ 25 ].
Cardiac or cardiovascular syncope is caused by various heart conditions, such as bradycardia, tachycardia or certain types of hypotension. It can increase the risk of sudden cardiac death.
People suspected of having cardiac syncope but who don't have serious medical conditions may be managed as outpatients. Further inpatient evaluation is needed if serious medical conditions are present. Conditions that may warrant hospital evaluation and treatment include various cardiac arrhythmic conditions, cardiac ischemia, severe aortic stenosis and pulmonary embolism.
If evaluation suggests cardiac vascular abnormalities, an ambulatory external or implantable cardiac monitor may be required. Heart failure , atrial fibrillation and other serious cardiac conditions can cause recurrent syncope in older adults, with a sharp increase after age Younger people without cardiac disease but who've experienced syncope while standing or have specific stress or situational triggers aren't as likely to experience cardiac syncope.
Cardiac syncope is a higher risk in: people older than age 60; men; presence of known heart disease; brief palpitations or sudden loss of consciousness; fainting during exertion; fainting while supine; an abnormal cardiac exam; or family history of inheritable conditions. Other existing conditions and medications used are particularly important in older patients. People who experience the warning signs of fainting of dizziness, nausea and sweaty palms should sit or lie down.
Anyone with syncope should receive an initial evaluation, including detailed physical and history examinations and measurement of blood pressure and heart rate, by a physician. An ECG electrocardiogram also is recommended as part of an initial evaluation to provide information about the cause of syncope. ECG is widely available and inexpensive and can provide information about the potential and specific cause of syncope for example, abnormal heart rhythms.
Other tests, such as exercise stress test , Holter monitor and an echocardiogram , may be needed to rule out other cardiac causes. An ECG also is recommended for children and young adults with syncope. Other noninvasive diagnostic testing may be needed if they're suspected of having congenital heart disease , cardiomyopathy or a heart rhythm disorder. If the initial evaluation is unclear, it may be useful for patients to undergo a tilt test. The blood pressure and heart rate will be measured while lying on a board and with the board tilted up.
People with NMS usually will faint during the tilt, due to the rapid drop in blood pressure and heart rate. When people are placed on their back again, blood flow and consciousness are restored. Patients with VVS and without a serious medical condition usually can be managed in an outpatient setting.
Pathophysiology Cough is a defensive mechanism designed to remove mucous and foreign material from the airways. Several pathophysiologic processes may cause or contribute to cough-related syncope: Valsalva-induced decreased cardiac output. Confusing conditions Cough syncope may be confused with epilepsy, particularly as the syncopal attacks may be associated with secondary arrhythmic convulsive jerks of the extremities ie, convulsive syncope 48 ; 47 ; 21 ; 39 ; 31 ; Associated or underlying disorders The cause of cough in patients with cough syncope is variable, but most commonly is associated with chronic obstructive pulmonary disease.
Cough syncope: case presentation and review. J Allergy ;46 6 PMID Chiari type I presenting as left glossopharyngeal neuralgia with cardiac syncope. Neurosurg Rev ; Cough syncope induced by post nasal drip successfully managed by Gabapentin.
Respir Med Case Rep ; Pertussis outbreak among adults at an oil refinery--Illinois, August-October Mechanism of cough syncope. Orv Hetil ; 31 Cough syncope with herpetic tracheobronchitis. Isr Med Assoc J ;3 4 Cough syncope presenting as Mobitz type II atrioventricular block--an electrophysiologic correlation.
Pacing Clin Electrophysiol ; Syncope in an adult with uncontrolled asthma. South Med J ; Effect of cough on heart rate and blood pressure in patients with "cough syncope". Heart Rhythm ;2 8 Smoking and cough syncope: follow-up in 45 cases. Int J Addict ; Giant left atrial myxoma masquerading as cough-syncope syndrome.
Neurally-mediated syncope. Ital Heart J ; Guidelines on management diagnosis and treatment of syncope. Eur Heart J ; Photopsias: a key to diagnosis. Ophthalmology ; 10 Cough syncope treated with a long-term vasoconstrictor. JAMA ; Gaz Med Paris ; Prog Med Paris ; Cough syncope caused by sinus arrest in a patient with sick sinus syndrome. J Neurol Neurosurg Psychiatry ; Am J Prev Med ; EEG in cough syncope. Neurology ; Carotid blood velocity during cough studies in man.
Stroke ; Cough syncope from constrictive pericarditis: a case report. Can J Cardiol ; Vasodepressor cough syncope masked by sleep apnea-induced asystole. J Cardiovasc Electrophysiol ;23 9 Respir Med ; 2 Cough syncope and tracheal compression secondary to a retrosternal goitre: looking for a pulmonary embolism.
BMJ Case Rep ;12 4. Syncope in the adult Chiari anomaly. Neurology ;28 7 Pericardial effusion presenting as cough syncope. Acute Med ;19 2 Case report: cough syncope in a U. Army aviator. Aviat Space Environ Med ; Intractable hiccups and syncope in multiple sclerosis. Acta Neurol Scand ; Cough syncope misinterpreted as epileptic seizure. Epileptic Disord ;10 3 Neurocardiogenic syncope. N Engl J Med ; Cough syncope and gastroesophageal reflux.
A self-observation by Paul Valery [in French]. Presse Med ;23 25 Cough syncope as a cause of traffic accident [in German]. Blutalkohol ;27 2 Physiologic relationships between intrathoracic, intraspinal, and arterial pressures. Arterial, cerebrospinal and venous pressures in man during cough and strain.
Am J Physiol ; Syncope as a presenting feature of hindbrain herniation with syringomyelia. J Neurol Neurosurg Psychiatry ;45 10 Syncope caused by cough-induced complete atrioventricular block. Cough syncope mimicking epilepsy in asthmatic children. Can J Neurol Sci ; Comentarii de morborum historia et curatione.
London: T Payne, Sudden illness as a cause of motor vehicle accidents. Br J Int Med ; Gastroesophageal reflux in chronic cough and cough syncope and the effect of antireflux treatment: case report and literature review.
Ann Otol Rhinol Laryngol ; 10 Orv Hetil ; Evaluation of the autonomic cardiovascular response in Arnold-Chiari deformities and cough syncope syndrome. Arch Neurol ; Cough syncope induced by enalapril.
Chest ; Cough syncope: a complication of adult whooping cough. Br J Dis Chest ; Cough syncope in children with asthma. J Pediatr ; The syndrome of cough syncope. Ann Intern Med ; Cerebral concussion as a cause of cough syncope. Arch Intern Med ; Sharpey-Schafer was right: evidence for systemic vasodilatation as a mechanism of hypotension in cough syncope. Europace ;10 4 Cough syncope induced by gastroesophageal reflux disease. J Cardiol ;54 2 Ventricular asystole during vagus nerve stimulation for epilepsy in humans.
Herniated cerebellar tonsils and cough syncope. J Neurosurg ; Potential risk of vasovagal syncope for motor vehicle driving. Am J Cardiol ; Cough syncope: the possible relation to hydrocephalus ex vacuo. Eur Neurol ; Critical carotid and vertebral arterial occlusive disease and cough syncope.
A potential novel variant of hereditary sensory neuropathy in a year-old man with cough-induced syncope and vertebral artery dissection. Mayo Clin Proc ; Syncope, driving recommendations, and clinical reality: survey of patients. Br Med J ; Laryngospasm: an atypical manifestation of severe gastroesophageal reflux disease GERD. Laryngoscope ; Syncope: driving advice is frequently overlooked. Postgrad Med J ; Chiari I malformation associated with atlanto-occipital assimilation presenting as orthopnea and cough syncope.
0コメント