(extensive description edited by Dr J)
My question is in reference to my husband. He has developed diabetes mellitus, though his HA1C was 6.4 when last measured. Normal blood sugars range from 100-120 with some higher and lower fluctuations. He takes Glucophage and Glucotrol for sugar control. He has some diabetic neuropathy from the balls of his feet through his toes. He has been diagnosed with coronary artery disease and has had at least one heart attack, noted in the past year. He has high blood pressure. He has been shown to have 50% carotid occlusion on the right side, 30% on the left.

Two days after the first catheterization in April 2004, the dental clinic at the hospital pulled seven of his teeth at one time under questionable local anesthesia. During the extractions, they managed to open a hole in his upper jaw into his sinus.

Approximately 24 hours later, his pulse began to drop through the 60s, 50s and into the low 40s (43). He complained of nausea, became diaphoretic, agitated, confused, disoriented, experienced white or grayed out vision, and thought he smelled smoke or burning. His BP dropped to 67/43 and his pulse ox dropped to 88. Eventually, he lost consciousness and fell into a deep sleep from which he was unable to be roused for about two hours.

When he regained consciousnessâ, he was extremely drowsy, disoriented, and had no memory of what had happened immediately preceding and during the syncopal episode.

Since that episode, he has experienced the same scenario about 100-150 times. The number is not completely clear because he does experience this problem during the night and work day when he is essentially alone.

1. Not positional
2. Does not seem to be narcotic related. He’s been on the same medication regimen for almost eight years and never suffered from these episodes. Plus, during various hospital stays, staff has removed him from the medication, varied the dose administration and timing.
3. Does not seem to be diabetic in nature. Blood sugars have been measured at normal levels and at extremely high levels (due to removal of glucophage for catheterization procedures). Syncopal episodes still seem to be the same.
4. Has had tilt table test. Test was ruled conditionally negative. The nurse was unable to induce the syncopal episode; however, he’d just received 48 hours of IV fluids following the stent placements.
5. Other EP doctors have refused to repeat tilt test because they feel that the duration of the unconscious period (10 minutes to 5 hours) negates neurocardiogenic origins.
6. There is no response to pain stimulus when in syncopal episodes.
7. He does have the ability to pop out of episodes to carry on 45 seconds of lucid conversation after which he returns to completely unconscious state with amnesia regarding the lucid conversation
8. EEG was run during syncopal episodes. Negative results.
9. CT Scan was run. Negative results.
10. EKG was run with computer generated note stating 2nd degree AV block, however, no other information was able to be gained.
11. Event monitor was worn for a month. NSR recorded for each syncopal event.
12. Greyhound pets seem to be able to sense onset of syncopal episodes even when he can’t and bark persistently to alert him to find safe position
13. A tentative diagnosis of autonomic neuropathy was tossed about but shelved when he didn’t have a significant number of other symptoms.

So, we’re left with the problem where he’s consistently passing out, whether at home or in the hospital or on the way to the doctor’s office. Nobody has been able to tell us what to do or whether to consider each episode an emergency.

I would assume a blood pressure of 67/43 would be cause for alarm, but he’s always come back out of it after a period of time has passed so, we’re not certain how to handle this.

I’ve researched everything I can think of and seem to be coming up empty.

?

Dr. Joshua’s Answer:

Thank you for your question. Your husband has been thoroughly examined, and seen by the relevant specialists. I’m afraid I cannot be of significant help to you, because making a diagnosis over the Internet is even harder than making one in real life.?

I can only offer you my own opinion, which is based purely on what you wrote about the history of these attacks. I’m not a cardiology expert, and it seems that cardiac origin of these attacks has been ruled out by specialists in that field. From a neurological viewpoint, the only examinations that might be informative, and have not been performed, are MRI of head and neck, and video-EEG. Consult your husband’s neurologist about these. If the neurologist thinks these investigations are necessary, they will be done, and if he does not, then we should accept that.

Apart from that, there are a couple of things which I might recommend. First, a carbamazepine trial, i.e. start him on carbamazepine (if suitable for him and check compatibility with other meds) anyway, just to see whether it might work, even though epilepsy has been ruled out. It’s not really logical, but sometimes it does work. The other consideration is that the problem may be of psychogenic origin, e.g. conversion syncope. Also, from the description you gave me, it seems the episodes involve a catatonic-like state. Have you noticed anything that might trigger these attacks? Sometimes, conversion syncope may be triggered by merely talking or thinking of something which is a sensitive, traumatic topic for the patient. In your husband’s case, it might be something related to medical procedures, or illnesses. Your husband has been through a lot, and the psychological stress must be enormous. My second recommendation therefore is to consult a psychiatrist with experience in this field, in order to rule out this possibility as well.

I’m sorry that I can’t offer any more specific recommendations. Please do consult your husband’s physicians if you have further questions about my answer. The answer I have given is purely to offer you an opinion, and to inform you of the possibilities that come to my mind.

PS. Based on current knowledge, Bextra should be discontinued because of ichemic heart disease

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