A rare cause of cardiac syncope mimicking epilepsy: Left main coronary artery stenosis

Abstract

Key words children, epilepsy, left main coronary artery stenosis, syncope.Although isolated congenital coronary anomalies are seen rarely in children (1% of all child patients undergo coronary angiography), this disorder has great importance because of its potential effects. 1 Isolated stenosis or atresia of the left coronary artery ostium is extremely rare. 2 Clinically, this can present in late childhood with myocardial infarction, ventricular tachycardia, chest pain, syncope or sudden death, while growth retardation and cardiac failure can be seen at infancy. 3 We report a patient diagnosed with isolated stenosis of the left main coronary artery (LMCA) ostium that presented with recurrent effort-related syncope and generalized tonic-clonic convulsions and was treated with antiepileptic agents as she was thought to suffer from epilepsy. No previous pediatric case has been reported where a misdiagnosis of epilepsy was made in a patient with coronary anomaly. This case emphasizes the role of accounting for coronary artery anomalies in the differential diagnosis of children who have a history of effort-related syncope and seizure. Case reportAn 8-year-old girl presented with recurrent syncope and seizures. Her family reported that initially the generalized tonic-clonic convulsions lasted 10 min and started while playing around in the morning four years earlier and was later accompanied by urinary incontinence. It was noted that oral secretions and cyanosis occurred during the seizure and vomiting occurred after waking. Valproic acid was initiated, considering the diagnosis as epilepsy. Due to the recurrent nature of the seizures, several studies including electroencephalogram (EEG), biochemistry, and cranial magnetic resonance imaging were ordered, and all remained negative. Because the patient's complaints continued one more EEG was performed and although no pathological results were seen clonazepam was added to the valproic acid that had been taken for one year. While taking history about her latest seizure, the family reported that all the seizures were related to effort. The patient was then referred to our center. No metabolic, cardiac or neurological disorders were noted in the family history. No other abnormality was detected during physical examinations including detailed cardiovascular and neurological examinations at which neuromotor and growth percentiles were normal.The complete blood count, serum biochemistry, serum lipid profiles and cardiac enzymes were normal in laboratory findings. No cardiomegaly was detected on chest X-ray. The 12-lead electrocardiogram ( Fig. 1) and 24-hour Holter electrocardiogram were normal. Cranial magnetic resonance imaging and sleep/ awake EEG were applied and no pathology was detected. Two dimensional, M mode, colored and tissue Doppler echocardiography results were normal. Because the complaints were related to effort an exercise test was applied. On the effort electrocardiogram, T-wave negativity was detected on DII and DIII derivations. Cardiac computed tomography (CT...