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What causes syncopes?

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Posted on Mon, 14 Jul 2014
Question: I am a 30yo female and have been having five to ten episodes of syncope everyday for the last 4 weeks. I presented to the ER originally and the ER doctor suggested, after blood work, that I may have an insulinoma and to follow up with my PCP. I followed up, got a glucometer, & monitored my sugar for about two weeks. Glucose never goes about 130 never goes below 50. Stays average at about 90-100. They use that to rule out the insulinoma. They sent me to a different hospital ER and that dr scanned my heart and sent me to a cardiologist. The cardiologist put me on a holter monitor. The holter monitor reveals nothing significant. An echocardiogram was performed and again nothing significant was revealed. About a week later, left supraclavicular lymph node enlargement was discovered and today I was supposed to go in for an ultrasound of the lymph node. I went in for my ultrasound and two techs tried and could not scan the lymph nodes because it/they kept falling underneath of the clavicle. What is my next step? What could the cause be? I feel like I'm being jerked around from doctor to doctor to doctor and I'm not getting any results. My PCP can't get me into an endocrinologist or neurologist for at least another month. My syncope continues to worsen and I'm growing more and more fatigued with each passing day. We still don't know what is causing the syncope. I'm off of work because I pass out too frequently and I'm so fatigued that I would just sleep the day away anyway. My labs reveal an abnormal white cell count. (I was originally diagnosed, the very first time I was seen, with mononucleosis because of this). My white cell count is still abnormal but they never tell me if its high or low. I'm worried, as a healthcare worker myself, about something worse like leukemia or lymphoma. Just need some peace of mind.
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Answered by Dr. Binu Parameswaran Pillai (3 hours later)
Brief Answer:
Hello

Detailed Answer:
Good day,

Noted your history. Sorry to hear that so far you haven't got an answer.

You have mentioned that glucose never went below 50. Were the readings taken durig the syncopal attacks ? If you had a reading of 50, i would suggest to do a 72 hour fasting hypoglycemia test. This need an endocrine input.

HAve you lost or gained any weight? Any fever?. Any papitations, hypotension episodes, increased BP, sweating or flushing during these episodes??

Noted that the brain CT and ECho , Holeter were normal. ( any EEG done?)

From an endocrine point of view, i would suggest a 72 hour fasting test to rule out hyperinsulism if you have touched a reading of 50 during episodes of syncope.

Besides, we need an answer to your supraclavicuar lymphnode and if there is any relation to that with syncopes. The rise in white cell count would suggest an infection. However, i do have to keep other rare diagnosis as well in my mind. Since ultrasound was not sucessful, the best option would be a CT scan and an needle test or biopsy from the lymphnode. Your thyroid also need imaging.

Have you had a thyroid testing ? If not, i would suggest a Thyroid function tests and a fasting calcium profie as well.

I do realise that, being healthcare workers, we get worried and think of most serious diagnosis first. Please relax. Arrange for a CT scan of your lymphnode area and an FNAC/biospy. You may also have to talk to our doc abot getting a 72 hour fastng test, Thyroid blood tests and thyroid imaging, fasting calcium profile.

I would keep other tests liike 24 hour urine catecholamines etc for later ( since the holter has not demonstreted any arrythmias).

Stay positive. Help is always available.
Wish you a speedy recovery

Regards
Binu
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Binu Parameswaran Pillai (5 hours later)
Hi Dr. XXXXXXX

Blood glucose was monitored upon waking, before meals, after meals and directly after syncopal episodes. Pre meal average was 75-88, post meal was between 108-128 (135 only once), it was 50 upon waking once and averaged between 60-80 after syncopal episodes.

I am a very active person, I used to run daily, but since about October when I took my new position at work, I have only been able to get on the elliptical machine to exercise, since I get home after dark and its not really safe to run here at night. I attributed that change and in the more recent weeks, my fatigue and inability to exercise due to it, to my recent weight gain. However, my diet has not changed. I did well keeping my weight steady until about March. I've gained about 50 pounds since March. The weight gain is why my PCP does not believe its lymphoma or worse because those patients typically lose weight. However, I have 2 lymph nodes in the supraclavicular region that I still want them to address.

A thyroid panel was ran at the first ER. Lab values were normal, but the low end of normal. Thyroid was scanned by ultrasound yesterday.
Thank you for your help and for giving me the next step. That helps a little with peace of mind. XXXXXXX

doctor
Answered by Dr. Binu Parameswaran Pillai (3 hours later)
Brief Answer:
Hi

Detailed Answer:
Hello,
Thank you for the reply. If you had one value of documented glucose of 50 mg, then i would surely recommend a 72 hour fasting test. Hypoglycemia can cause compensatory weight gain due to frequent feeding.

But this 72 hour fast test can cerrtainly wait. The priority would be to do an imaging of your chest and supraclavicular area and get a sample for FNAc/Biospy. Since you have no weight loss, that is really reassuring.

You are very welcome to ask more questions. But if you have no other question, you may please close the query now.

Wish you a speedy recovery

Binu

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Binu Parameswaran Pillai

Endocrinologist

Practicing since :2003

Answered : 1435 Questions

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What causes syncopes?

Brief Answer: Hello Detailed Answer: Good day, Noted your history. Sorry to hear that so far you haven't got an answer. You have mentioned that glucose never went below 50. Were the readings taken durig the syncopal attacks ? If you had a reading of 50, i would suggest to do a 72 hour fasting hypoglycemia test. This need an endocrine input. HAve you lost or gained any weight? Any fever?. Any papitations, hypotension episodes, increased BP, sweating or flushing during these episodes?? Noted that the brain CT and ECho , Holeter were normal. ( any EEG done?) From an endocrine point of view, i would suggest a 72 hour fasting test to rule out hyperinsulism if you have touched a reading of 50 during episodes of syncope. Besides, we need an answer to your supraclavicuar lymphnode and if there is any relation to that with syncopes. The rise in white cell count would suggest an infection. However, i do have to keep other rare diagnosis as well in my mind. Since ultrasound was not sucessful, the best option would be a CT scan and an needle test or biopsy from the lymphnode. Your thyroid also need imaging. Have you had a thyroid testing ? If not, i would suggest a Thyroid function tests and a fasting calcium profie as well. I do realise that, being healthcare workers, we get worried and think of most serious diagnosis first. Please relax. Arrange for a CT scan of your lymphnode area and an FNAC/biospy. You may also have to talk to our doc abot getting a 72 hour fastng test, Thyroid blood tests and thyroid imaging, fasting calcium profile. I would keep other tests liike 24 hour urine catecholamines etc for later ( since the holter has not demonstreted any arrythmias). Stay positive. Help is always available. Wish you a speedy recovery Regards Binu