dizziness

Introduction: Atrioventricular nodal reentrant tachycardia (AVNRT) is the most frequent supraventricular tachycardia, commonly manifesting as autolimited paroxysmal episodes of rapid regular palpitations that exceed 150 beats per minute (bpm), dizziness and pounding neck sensation. Case presentation: We present a case of a male patient, 70 years old, with ischemic heart disease and slow-fast AVNRT treated with radiofrequency catheter ablation (RFCA) in March 2019, with regular 6-months follow-ups. He was readmitted in our department in November 2020 for rest dyspnea and incessant fluttering sensation in the neck, without palpitations. The event electrocardiogram (ECG) was initially interpreted by general cardiologist as accelerated junctional rhythm, 75 bpm. Due to the persistence of symptoms and ECG findings, a differential diagnosis between reentry and focal automaticity was imposed. The response to vagal maneuvers and Holter ECG monitoring characteristics provided valuable information. We suspected recurrent slow ventricular rate typical AVNRT, which was confirmed by electrophysiological study and we successfully performed the RFCA of the slow intranodal pathway. Conclusion: AV nodal reentry tachycardia may have an unusual presentation, occurring in elder male patients with structural heart disease. Antiarrhythmic drugs can promote reentry in this kind of patients. In cases of slow ventricular rate, vagal maneuvers and Holter ECG monitoring can help with the differential diagnosis. The arrhythmia can be successfully treated with RFCA with special caution regarding the risk of AV block.

A 58-year-old hypertensive man presented to our insti-tution with acute chest pain and dizziness. Electrocardiogram revealed inferior wall myocardial infarction with suspected right ventricular involvement (Figure 1A). Computed tomographic aortography (CTA) depicted ascending aortic dissection (AAD) with involvement of bilateral carotid, subclavian, and right common iliac arteries (Figure 1B). Replacements of aortic valve and ascending aorta with CABG (Ao-RSVG1-LAD and Ao-RSVG2-RCA) were conducted. 

Vestibular disorders and anxiety are closely related, probably because they share some neuronal pathways. Ageing and patient comorbidities are important facilitating factors, and multiple vascular risk factors could contribute to the onset of a vestibular syndrome called vascular vertigo. White matter lesions (WML) are often seen on magnetic resonance imaging (MRI) scans of elderly people and are related to various geriatric disorders, including dizziness. The cause of this correlation could be the disruption of neuronal networks that mediate higher vestibular cortical function. Numerous neuronal pathways link the vestibular network with limbic structures and the prefrontal cortex modulates anxiety through its connections to amygdala. The aim of the present work was to investigate the correlation between WML, amygdala and cognitive functions.

Objective: Dysfunctional breathing (DB) refers to abnormal patterns of breathing. No gold standard exists for diagnosis. In clinical practice we regularly see children with functional breathing problems. We collected data from this patient group to gain more insight into the characteristics of children with dysfunctional breathing. Methods: We composed a retrospective, cross-sectional study. The population consisted of children referred to a physiotherapist by a pediatrician due to suspected dysfunctional breathing. Data from 2013-2015 were collected from patient files, selected according to patterns and onset of symptoms, concomitant asthma, Nijmegen questionnaire (NQ) score, maximum exercise capacity and breathing pattern. Results: A total of 201 patients were included in the study, 66% of whom were female. The mean age was 13.9 years; 26% of the children were overweight. The most frequently reported symptoms were breathlessness, chest pain/tightness and dizziness. Fifty-two percent had a NQ score ≥23, mainly female. Twenty-eight percent of the children scored < p5 for their age on maximum exercise capacity; this proportion was substantially higher among males. Of the total population, 78% scored < p50 for their age. Subgroups with a higher body mass index (BMI) showed lower maximum exercise capacity. Children presenting with pulmonary symptoms were primarily misdiagnosed with asthma. Conclusion: Dysfunctional breathing is a common cause of respiratory complaints. Most children with dysfunctional breathing have a high BMI and are in poor physical condition, which suggests a clinically relevant comorbidity and possible options for therapy. Children are often falsely diagnosed with asthma; better recognition will decrease unnecessary medication use.Introduction

Sojourn to high altitude may affect various human systems if proper acclimatization not followed. If acclimatization failed, sojourners may suffer with high altitude sickness such as acute mountain sickness (AMS), high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE). Although a sojourner’s tolerance to high altitude hypoxia varies according to differences in physiology and physical conditioning. Acute mountain sickness may cause headache, insomnia, dizziness, nausea, vomiting and fatigue. While HACE is more serious stage where brain swelling occurs and it is potentially fatal. A sojourner with HACE may experience confusion, amnesia, delusions, and loss of consciousness. Staying in high altitude (above 9000 feet) environment poses low oxygen supply (hypobaric hypoxia) to the different body organs including brain.

Acute dizziness/vertigo is among the most common causes for visiting the emergency department or primary care physician. Although the majority of these presentations represent an acute peripheral vestibulopathy (APV), lateral medullary, lateral pontine, and inferior cerebellar infarctions can mimic APV very closely. We present an atypical presentation of an aggressive APV and outline how a well-constructed bedside neurotologic evaluation can distinguish central from peripheral vertigo in the acute setting.

Background: Meclizine is a commonly prescribed medication for patients discharged from the Emergency Department (ED) with a diagnosis of peripheral vertigo, however it is on the Beers list of medications to avoid in elderly patients. Objectives: This study aims to determine the correlation between use of meclizine and return visits to the ED within 1 week in patients > 65 years old. Methods: This is a retrospective observational study conducted at 2 urban tertiary care EDs over 5 years. Inclusion criteria included patients > 65 years who were given meclizine in the ED or discharged with a prescription. Charts were reviewed for diagnosis, prescriptions and return visits within 7 days. Results: There were a total of 1608 patients over 65 years of age who met inclusion criteria, 669 patients identified as receiving meclizine in the ED and 962 who received no meclizine (ED or ED plus home prescription). Of the meclizine patients, 548 (84.8%) were given home prescriptions, of which there were 36 (6.6%) return visits within 7 days. Patients who were given meclizine while in the ED without home prescriptions (121) had 16 return visits (13.2%). Among the non-meclizine group, 102 patients (10.6%) had a return visit within 7 days. Conclusion: There was no increase in return visits in elderly patients discharged from the ED with a prescription for meclizine after a diagnosis of benign dizziness. Meclizine prescriptions at discharge were associated with fewer return visits to the ED within 1 week. Ongoing dizziness was the most common reason for return visits; there were no documented chief complaints of weakness, syncope/falls, or hypotension.

Many patients with chronic cerebrovascular diseases complain “dizziness”, which is a distortion of static gravitational orientation, or an erroneous perception of motion of the sufferer or of the environment. In the vestibular cortical system, the parieto-insular vestibular cortex (PIVC) serves as the core region having the strong interconnections with other vestibular cortical areas and the vestibular brainstem nuclei. By forming the reciprocal inhibitory interactions with the visual cortex (VISC), it also plays a pivotal role in a multisensory mechanism for self-motion perception. In a line of our studies on post-stroke patients, we found that there was a significant decrease in the cerebral blood flow in both the VISC and PIVC in the patients who suffered from dizziness. In this article, we provide a new concept that due to dysfunction of the visual-vestibular interaction loop, low cerebral blood perfusion in the PIVC and VISC might elicit post-stroke dizziness.

Background: Hyponatremia associated with COVID-19 is considered an independent risk factor for a prolonged hospital stay, intensive care admission, and death, but its causes and treatment are not yet well known. Many workers attribute hyponatremia associated with COVID-19 to acute kidney injury and nephropathy associated with the disease. Others suggest that it is related to the syndrome of inappropriate antidiuretic hormone secretion, sepsis, or hypothalamic-pituitary dysfunction. We report a case of persistent acute hyponatremia in a COVID-19 patient with multifactorial etiology. Case presentation: A managed 77 years with known hypertension, type II DM, ischemic heart disease, chronic kidney disease (stage 3B and on treatment) presented with post-COVID-19 pneumonia, confusion, fever, generalized fatigability, dizziness, and lower limb edema. COVID-19 ad has been diagnosed two weeks earlier with a positive nasopharyngeal swab and was managed with dexamethasone, 10 mg oral for 10 days, azithromycin, 500 mg once orally, and levofloxacin, 500 mg once orally. At presentation, laboratory investigation showed hyponatremia (127.7 mg/dl). Conclusion: The etiology of hyponatremia associated with COVID-19 is different from that in other cases of hyponatremia and its management should be individualized according to patient history and clinical assessment, and effort is needed to determine the exact cause.