Syncope and Recurrent Vertigo in an Older Woman

A 67-year-old woman was seen in the emergency department following of an episode of syncope. She described recurrent episodes of vertigo during the past 6 months. Most recently she had been talking on the telephone with her grandson when she experienced a sensation she described as “the room spinning,” accompanied by a generalized sensation of coldness. She then fell to the ground and lost consciousness. When she regained consciousness, she felt extremely tired and weak.

She sustained a bruise to her chin and left anterior chest wall from the fall. She estimated the episode to have lasted a few minutes. Her grandson, who accompanied her, had rushed to her home and called 911 after she stopped responding on the phone and he heard the sounds of her fall.

The patient had been worked up for a similar episode (including a fall and loss of consciousness) 6 months earlier, with no significant findings. She had been discharged with a supply of meclizine to take “as needed” but had several more episodes of non-positional vertigo with no temporal pattern. She had no repeated episode of syncope, however, until the current one.

She denied limb weakness, headache, excessive drowsiness, nausea, and vomiting. She claimed no palpitations, chest pain, and shortness of breath. Her exercise tolerance was preserved. She denied tinnitus but reported a long-standing history of reduced hearing in her left ear that followed a tympanic membrane rupture several years ago. Further probing revealed a mechanical fall with blunt head trauma earlier in the year; the current symptoms began approximately 1 month after this event.

Past medical history was significant for diabetes mellitus type 2, hypothyroidism, hyperlipidemia, and hypertension, all of which were well controlled with medications: aspirin, hydrochlorothiazide, rosuvastatin, glyburide, metformin, synthroid, and valsartan.

On physical examination, the patient’s vital signs were stable with no orthostasis. Glucose level was 107 mg/dL based on finger stick test. A tongue bite with bruising, as well as the bruises on her chin and chest wall were noted. Findings from the rest of the examination were unremarkable. Dix-Hallpike maneuver was negative. Serology revealed only a mild chronic microcytic anemia.

An ECG revealed normal sinus rhythm. A chest radiograph was unremarkable and a CT scan of the brain was negative. Results of recent workup done after the similar episode 6 months earlier, including carotid Dopplers and echocardiogram, were normal.

Based on the current information, what is your diagnosis?
 

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