https://orcid.org/0000-0002-6847-4582
A 60-year-old man without a medical history was admitted to our hospital for syncope assessment. He had recently experienced 3–4 syncopal episodes at rest lasting ∼1 min. The resting electrocardiographic, transthoracic echocardiographic, and exercise test results were normal. Head-up tilt test and electrophysiological study results were also unremarkable. He was discharged with an implantable cardiac monitor (Confirm RX, Abbott®). At the 1-month follow-up, loop recordings revealed 11 sinus pauses of 6–20 s (see Supplementary material online, Figure S1). He had olfactory or gustatory hallucinations, usually triggered by negative stress or positive emotion. Cerebral magnetic resonance imaging demonstrated right amygdala asymmetry and left insula asymmetry. Investigations ruled out autoimmune, infectious, and paraneoplastic origins. A diagnosis of limbic encephalitis or ictal syncope was considered, but ictal syncope was the most probable diagnosis. Lacosamide treatment (50 mg twice daily) was initiated. Rare olfactory hallucinations continued for 6 months, but no syncopal or arrhythmic events were observed (Panel). Lacosamide was discontinued because it was only partially effective for preventing hallucinatory episodes. Two months later, recordings revealed six sinus pauses of ≥7 s, so lacosamide was reintroduced. In 24 months of follow-up, no syncopal or asystolic episodes had been observed.
Supplementary material is available at Europace online.
The full-length version of this report can be viewed at: https://www.escardio.org/Education/E-Learning/Clinical-cases/Electrophysiology.
