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Tussive Syncope

Cough Syncope

Tussive syncope is the loss of consciousness following prolonged episodes of vigorous coughing. Patients recover spontaneously a few seconds to minutes later. This condition is associated with overweight middle-aged males with a history of smoking and chronic obstructive lung disease. The diagnosis is based on a detailed history, physical exam, and the appropriate studies.


Presentation

Tussive syncope, a well-recognized condition, is characterized by a brief loss of consciousness following vigorous coughing [1] [2]. This syndrome is typically observed in middle-aged men who are overweight smokers with underlying chronic obstructive lung disease (COPD) [3] [4]. Tussive syncope can also occur in children with asthma as well [5] [6]. The exact mechanism of tussive syncope is not fully elucidated [1] [2]. It is important to note, however, that since tussive syncope and adult tussive cough are common [1] [2], it is likely that pertussis is underdiagnosed in this age group [1] [2] [7]. Moreover, tussive syncope may also be associated with underlying diseases of respiratory, cardiovascular, and central nervous systems [8].

Patients with tussive syncope experience intense and prolonged episodes of coughing prior to losing consciousness, The syncope is rapid, lasts for a very short duration, and resolves spontaneously and completely [1] [2]. In addition to a paroxysmal cough, other features may include cyanosis and signs related to congestion of the face [2]. Furthermore, the syncope may be accompanied by movement disorders without postictal confusion and loss of bladder or bowel control [3] [9] [10]. Also, visual disturbance and lightheadedness may precede the syncopal episode [3] [9]. Antitussive medications and management of chronic obstructive lung disease will cause the decrease of syncope episodes [3] [11].

Vital signs may be normal [2]. Notable findings may include wheezing [3].

Choking
  • When I cough, even a little, I begin to choke and eventually pass out. Sometimes I fade to grey and maintain consciousness, other times racing disjointed thoughts accompany slight convulsions.[medhelp.org]
Right Upper Quadrant Pain
Scanning Speech
  • Synonym(s): intermittent claudication Charcot triad - (1) in multiple (disseminated) sclerosis, the three symptoms: nystagmus, tremor, and scanning speech; - (2) combination of jaundice, fever, and upper abdominal pain that occurs as a result of cholangitis[medical-dictionary.thefreedictionary.com]

Workup

Any patient with syncope needs a full workup consisting of the personal medical history, full physical exam, and the appropriate studies. Specifically, details surrounding the onset of the syncope and the overall clinical picture are necessary to differentiate tussive syncope from similar presentations such as seizures and other causes of syncope [3].

The initial workup should include the complete blood count (CBC), which is typically normal. Additionally, biochemical tests are important to rule out hypoglycemia or other metabolic abnormalities. Very importantly, cultures of the blood, sputum, and throat are usually negative for the typical offending organisms [2].

With regards to diagnosing pertussis, polymerase chain reaction (PCR) analysis of nasopharyngeal samples can detect Bordetella pertussis [1] [2]. Furthermore, serologic tests constitute a sensitive method for the identification of pertussis in adult patients [1]. Pertussis has been discovered in patients with prolonged coughing which highlights the notion that adult cases of pertussis are probably not diagnosed or reported adequately [12].

Chest radiography, which is likely to be normal, should be performed in these patients [1]. Moreover, syncope associated with a cough requires assessment with pulmonary function tests (PFTs) to determine the presence of lung disease [3].

During further evaluation of syncope, the workup should include an electrocardiogram (ECG), echocardiogram, and a 24 hour ECG monitoring, which are all unremarkable [1] [2].

Neurologic workup includes computed tomography (CT) scan of the head and electroencephalography (EEG), which will exclude seizures or some other central nervous system (CNS) causes [1] [3].

Sinus Arrest

Treatment

  • Tussive syncope is a rare condition that often responds to treatment of the underlying cause of coughing. Therefore, the workup and diagnosis of the cause is essential. However, at times, the cough is refractory to conventional treatment.[ncbi.nlm.nih.gov]
  • Management of cough syncope focuses on treatment of the cough (eg, bronchodilators and antitussives) and the underlying conditions. Smoking cessation is closely associated with decreased symptoms and should be strongly encouraged.[medlink.com]
  • Management of cough syncope focuses on treatment of the cough (eg, bronchodilators and antitussives) and the underlying conditions.[pdffiller.com]
  • In this situation, one approach to treatment would be to give anti-tussive (anti-cough) therapies. Some examples would be dextromethorphan (found in some cough syrups) or codeine.[answers.yahoo.com]
  • Treatment Most effort is aimed at treating the cough with cough suppressants, and exhaling before coughing. If the patient has an central or peripheral dysautonomia, treatment should be directed towards correcting that disorder too.[dizziness-and-balance.com]

Prognosis

  • The long-term prognosis of cough syncope depends largely on the prognosis of the underlying condition, but cough syncope itself can result in severe bodily injury, including vertebral artery dissection.[medlink.com]
  • Prognosis Cardiac syncope has a poorer prognosis than other forms of syncope. The 1-year endpoint mortality has been shown to be as high as 18-33%.[emedicine.medscape.com]
  • Vasodepressor syncope carries a worse prognosis in the elderly than with younger patients.[ahcmedia.com]

Etiology

  • […] either with momentary premonitory symptoms or without warning, due to cerebral anemia caused by ventricular asystole , extreme bradycardia , or ventricular fibrillation . neurocardiogenic syncope a particularly serious type of vasovagal attack ; the etiology[medical-dictionary.thefreedictionary.com]
  • Syncope in a patient with poor baseline cardiac function portends a poor prognosis, irrespective of etiology.[emedicine.medscape.com]
  • In addition, an expeditious approach for pinpointing the etiology of syncopal episodes is presented.[ahcmedia.com]
  • Practically all categories in the chapter could be designated 'not otherwise specified', 'unknown etiology' or 'transient'.[icd10data.com]
  • Clin Sci (Lond) , 2002 , vol. 102 (pg. 639 - 44 ) 49 Relation between motion sickness susceptibility and vasovagal syncope susceptibility , Brain Res Bull , 2006 , vol. 68 (pg. 217 - 26 ) 50 Orthostatic intolerance: emerging genetic and environmental etiologies[academic.oup.com]

Epidemiology

  • Special attention has also been paid to epidemiology and prevention, discussing all the issues concerned.[books.google.de]
  • Quality of studies Overall, the epidemiological evidence of the association studies is weak. In most studies, the sample size was smaller than 100 subjects.[academic.oup.com]
  • Epidemiology United States statistics Framingham data demonstrate a first occurrence rate of 6.2 cases per 1000 patient-years. [ 8 , 9] Syncope reoccurs in 3% of affected individuals, and approximately 10% of affected individuals have a cardiac etiology[emedicine.medscape.com]
  • -The Editor Epidemiology Syncope is a common presenting complaint among patients presenting to the ED and accounts for about 1-6% of all ED visits. 3,4 The Framingham study found a 3.3% incidence of syncope in a cohort of patients followed over a 26-year[ahcmedia.com]
Sex distribution
Age distribution

Pathophysiology

  • Overview In this article, the author explains the clinical presentation, pathophysiology, diagnostic workup, and management of cough syncope.[medlink.com]
  • SYN: Morgagni Adams Stokes s.. cardiac s. fainting with unconsciousness of any … Medical dictionary Laughter-induced syncope — is an unusual but recognized form of situational syncope (fainting) likely to have a similar pathophysiological origin to tussive[medicine.academic.ru]
  • Laughter-induced syncope is an unusual but recognized form of situational syncope (fainting) likely to have a similar pathophysiological origin to tussive syncope.[en.wikipedia.org]
  • Pathophysiological basis  Gradual failure of cerebral perfusion, with a reduction in cerebral oxygen availability.  Cerebral perfusion/oxygenation cut off for 8–10 s,  then loss of consciousness and postural tone,  pallor and sweating,  brief (lasting[slideshare.net]
  • Pathophysiology Syncope occurs as a consequence of global cerebral hypoperfusion. [1] Brain parenchyma depends on adequate blood flow to provide a constant supply of glucose, the primary metabolic substrate.[emedicine.medscape.com]

Prevention

  • To prevent tussive syncope, the origin of the cough must be researched and supported.[health.ccm.net]
  • Special attention has also been paid to epidemiology and prevention, discussing all the issues concerned.[books.google.de]
  • Individuals with Tussive Syncope should learn to recognize the warning signs of an oncoming loss of consciousness and move accordingly to prevent injury when they lose consciousness.[novusbio.com]
  • .: Prevention of hip fracture in elderly people with use of a hip protector. ‎[books.google.de]
  • The management and prevention of cough syncope is directed at the aggressive control of bronchospasm in children with asthma.[cambridge.org]

References

Article

  1. Kogana Y, Eliasa N, Slobodina G, Odeh M. Recurrent Cough Syncope Due to Pertussis in Adults: Report of Three Cases and Review of the Literatur. J Med Cases. 2016; 7(7): 266-269.
  2. Dawood H, Eliasa N, Slobodina G, Odeh M. Recurrent Cough Syncope Due to Pertussis in an Adult: A
    Case Report and Review of the Literature. J Med Cases. 2015;6(1):33-35.
  3. Deshmukh A, Schuller D. Case Report: Cough syncope in a patient with severe chronic obstructive pulmonary disease. Respir Med CME. 2008; 1(2):120-122.
  4. Krediet CT, Wieling W. Edward P. Sharpey-Schafer was right: evidence for systemic vasodilatation as a
    mechanism of hypotension in cough syncope. Europace. 2008;10(4):486-488.
  5. Haslam RH, Freigang B. Cough syncope mimicking epilepsy in asthmatic children. Can J Neurol Sci. 1985;12(1):45-47.
  6. Katz RM. Cough syncope in children with asthma. J Pediatr. 1970;77(1):48-51.
  7. Gabutti G, Azzari C, Bonanni P, et al. Pertussis. Hum Vaccin Immunother. 2015;11(1):108-117.
  8. Dicpinigaitis PV, Lim L, Farmakidis C. Cough syncope. Respir Med. 2014;108(2):244-251.
  9. Kerr A, Jr., Derbes VJ. The syndrome of cough syncope. Ann Intern Med. 1953;39(6):1240-1253.
  10. Demaria A, Westmoreland B, Sharbrough F. EEG in cough syncope. Neurology, 1984; 34(3):371-374.
  11. Bekman TJ. Syncope in an adult with uncontrolled asthma. South Med J. 2002; 95(3):369-370.
  12. Syed MA, Bana NF. Pertussis. A reemerging and an underreported infectious disease. Saudi Med J. 2014;35(10):1181-1187.

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Last updated: 2018-06-22 08:56