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An Unusual Syncope Case
HK is an 83 yo woman complaining of pruritic “hives” (small red bumps) one day ago on trunk and thighs accompanied by nausea and lightheadedness. Her left eyelid also became swollen. Symptoms occurred at rest and lasted two hours.
Unfortunately, we had no camera in the office during her initial. The swelling of her eyelid lasted a bit longer than the bumps on her trunk and thighs. Her lightheadedness represented presyncope.
She had many similar episodes in the past six months. During one episode, she had syncope and was hospitalized. She was diagnosed with orthostatic hypotension.
Past Medical History
Her fluoxetine was begun recently, thinking that her recurrent presyncope could be caused by depression.
ROS: nausea/emesis and dizziness with pruritic rash, some memory impairment, no fevers, no headache, no palpitations, no chest pain or dyspnea
Questions to address:
Angioedema: The sudden swelling of dermis and subcutis; it frequently involves the mucous membrane and resolves over 24-72 hours. Angioedema is more painful than urticaria.
Urticaria and angioedema have been recognized since antiquity.
Natural History of Urticarial Disease
As in many other conditions, the disease presentation of urticaria is different in older adults. Older adults with urticaria have more severe presentations and are more likely to also experience angioedema (50% of adults with urticaria). Urticaria with angioedema is also more likely to persist over time.
Classification of Urticaria
A nonimmunologic urticaria resulting in mast cell degranulation (and release of histamine) can be triggered by many mechanisms including antigens, acetylcholine, the complement cascade, narcotics, physical stimuli, prostaglandins, and beta adrenergic agents..
The systemic features of cholinergic urticaria can be serious. When systemic features are prominent, the disorder can be confused with exercise-induced anaphylaxis. However, in exercise-induced anaphylaxis, an antigen or drug is usually required as well as exercise in order to trigger the syndrome. The response to exercise will vary according to other conditions but can be life-threatening.
Other types of urticaria
Treatment for physical urticaria
For cholinergic urticaria, nonsedating H1 blockers are now the standard of care. Sedating antihistamines are particularly risky for older adults due to CNS side effects.
People with one type of physical urticaria often will have other types as well. These entities are more common in younger adults, but clearly can also be seen in older adults.
This patient’s syncope could be diagnosed and treated without a tilt-table test, electrophysiology study, EEG, or any other medical test.
Although geriatricians see clinical syndromes that are at times quite treatable, sometimes the actual pathophysiology can’t be described. This scenario is common in environmental medicine. Physical stimuli affect the body through mechanisms which are not yet well-defined.