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''Roland D. Thijs, Robert H.A. Reijntjes, J. Gert van Dijk''<br/> | |||
''Department of Neurology and Clinical Neurophysiology, Leiden, The Netherlands''<br><br/> | |||
{{case_present| | |||
A 20-year-old male pupil of a sporting school had | |||
had attacks of lightheadedness over several months. The | |||
first time he felt unsteady and fell to the ground when he | |||
dismounted his bicycle after 1-hour of moderate exercise. In addition, he had chest pain and was short of | |||
breath. He was not certain whether or not he had passed | |||
out. Nobody had witnessed the event. For two hours afterwards he complained of unclear vision as if “looking | |||
through salad oil”. He had not been incontinent, had | |||
sustained no bruises and no tongue bite. Later, similar | |||
attacks occurred during light cycling, after competition | |||
skating, after skiing and during miction after exercise. He has a medical history of asthma and migraine. Both | |||
a cardiologist and a pulmonologist had analyzed the | |||
presenting complaints previously but could not find an | |||
explanation. Previous examinations had consisted of an | |||
ECG, echocardiography, bicycle stress testing, laboratory screen, chest X-ray and a lung perfusion scintigraphy. His medications were formoterol inhalations 12 | |||
mcg bid, budesonide inhalations 200 mcg bid and pantazol 20 mg od. The patient did not use coffee, nicotine | |||
or drugs. On physical examination no abnormalities | |||
were noted. The patient’s supine blood pressure (BP) | |||
was 110/65 mmHg with a resting heart rate (HR) of 70 | |||
beats per minute (bpm). Neurological examination | |||
showed slightly impaired fine motor skills and frequent | |||
eye blinks either left or right sided.}} | |||
== Treatment == | |||
A magnetic resonance imaging study of the brain was | |||
normal. Test of HR and BP during rest (70 bpm; | |||
108/65 mmHg), deep breathing, standing up (85 bpm; | |||
121/91 mmHg),a Valsalva maneuver and sustained hand | |||
grip were all normal. A tilt-table test (without medication) showed no abnormalities. Cathecholamine concentrations in plasma were obtained by venapuncture in | |||
both supine and after 30 minutes upright position (norepinephrine(NE): 1.22 nmol/l vs. 3.67 nmol/l, epinephrine(E): 0.13 vs. 0.16 nmol/l, dopamine(DA): 0.04 | |||
vs. 0.07 nmol/l, respectively) and in 24-hour urine (NE: | |||
0.43 µmol, E: 0.06 µmol, DA: 2.46 µmol). | |||
In view of the relation to exercise, the patient was | |||
asked to mimic a typical bicycle tour on an ergometer, | |||
while EEG, ECG and BP (Finapres, finger photoplethysmography) were continuously monitored. Cycling at | |||
maximal effort increased HR up to 185 bpm (mean ± | |||
standard deviation: 176 ± 7 bpm) without significant BP | |||
changes (systolic BP (SBP) 119 ±14mmHg; diastolic BP | |||
(DBP) 72 ±9 mmHg). Immediately after cessation of exercise BP fell to 75/45 mmHg, during which the patient | |||
felt unsteady and complained of blurred vision; there | |||
was no loss of consciousness. During the BP drop, electrocardiography revealed sinus tachycardia of 180 bpm. | |||
The patient recognized the sensations as similar to those | |||
of spontaneous attacks. A second exercise test was performed two weeks later, 15 minutes after rapid consumption of 1000 mL water. Symptoms did not recur at | |||
the second test. Compared to the first cycling test the | |||
maximal rise of HR during exercise was reduced to 155 | |||
bpm and the BP raised during exercise (SBP | |||
149 ± 21 mmHg; DBP 94 ± 14 mmHg). No significant BP | |||
drop occurred after cycling. Fig. 1 displays the changes of heart rate and blood pressure during both tests. Furthermore exercise-related symptoms were succesfully | |||
prevented by water ingestion. However, after 2 months | |||
our patient complained of attacks during ordinary daily | |||
activity. As these attacks could not be anticipated and | |||
occurred frequently, we advised to stop the extra water | |||
ingestion and precribed sodium tablets (7.2 g/day) instead. After 2 months he had had no complaints. | |||
== References == | |||
<biblio> | |||
#Bjornstad | |||
#Calkins | |||
#Colivicchi | |||
#Fleg | |||
#Grub | |||
#Holtzhausen | |||
#Jacob | |||
#Jordan | |||
#Kosinski2000 | |||
#Kosinski1996 | |||
#Sakaguchi | |||
#shannon | |||
#Sneddon | |||
#Takase | |||
#Wolthuis | |||