This is an 81–year–old woman with rate controlled atrial fibrillation, hypothyroidism and invasive ductal carcinoma, which was diagnosed in 2008, and treated with breast sparing surgery and radiation. At her first ER visit, she presented with severe neck pain that radiated to her left shoulder associated with diaphoresis, weakness and lightheadedness. She was ruled out for acute coronary syndrome and discharged with a diagnosis of muscle spasm. Two weeks later she was admitted for left shoulder pain, two syncopal episodes and weight loss. A CT scan of her chest showed a left soft tissue infiltrating mass along with supraclavicular and axillary lymphadenopathy. A lymph node biopsy confirmed recurrent stage III breast cancer. She was discharged, and 2 weeks later she presented again with syncopal episodes along with prodrome symptoms of dizziness, diaphoresis and the urge to defecate. On exam, she had a palpable mass in her left neck and supraclavicular region, as well as left–sided ptosis and miosis, consistent with Horner’s syndrome. These findings were a change in exam from earlier visits. The next morning she was found unresponsive, with a pulse in the 30 s and a systolic blood pressure of 60 mm Hg. She regained consciousness spontaneously. CT angiography showed a left supraclavicular mass causing mass effect on her left common carotid artery. Based on the location of the mass, surgery was not an option. She became symptomatic with palpation of her left carotid artery, which was thought to be related to tumor compression leading to carotid hypersensitivity. Since she did not have sustained bradycardia during her episodes, it was believed to be related to a vasodepressive rather than cardioinhibitory response. Therefore, a pacemaker would provide no benefit. She was treated with removal of AV–nodal blocking agents, compression stockings, midodrine, fludrocortisones, postural exercises, and palliative radiation.
Syncope is one of the most common presenting symptoms, making up 1–3% of all ER visits and hospital admissions in the United States. Carotid sinus syncope occurs with hypersensitivity of the carotid sinus reflex arc resulting in vagal activation or sympathetic inhibition. This can be associated with bradycardia and vasodilation, in which parasympathetic activation causes vasovagal symptoms. The goal of treatment is supportive, using vasoconstrictive medications, palliative surgery, radiation and chemotherapy when appropriate. Cardiac pacemakers are generally not effective.
This case represents an unusual presentation of syncope from locally invasive recurrent breast cancer. This situation demonstrates the importance of something as simple as performing a thorough history and physical exam. As hospitalist admit a majority of syncope patients, an emphasis on the basics can lead to an earlier diagnosis thus improving efficiency, reducing readmissions, and benefitting patient care.