Abstracts

Rationale: To describe an unusual presentation of hormonally inactive paraganglioma manifesting as syncopal/presyncopal spells. Methods: The patient, a 38-year-old right-handed woman, presented to Epilepsy clinic for evaluation of recurrent spells occurring with a frequency of 5-20 times/day and a duration of up to 3 minutes at a time. The spells were characterized by an aura of a "rushing" cephalic sensation, "racing thoughts" and a sense of "spaciness" or "dizziness" followed by loss of awareness with subsequent amnesia for the event. She was admitted to the epilepsy monitoring unit, where her typical spells were recorded. The EEG during the spells showed diffuse 3-4 Hz slowing, while the single-lead ECG monitor showed prolonged pauses in QRS complexes of up to 15 seconds. The patient was transferred to a cardiology unit and evaluated for a pacemaker. During that evaluation, she happened to ask the attending physician whether her "swollen lymph node" could be playing a role in her disorder. On examination, a 3 cm tender nodule was palpated at the angle of the left jaw. Palpation of the mass produced lightheadedness without heart rate changes. Contrast CT scanning of the chest and neck revealed a 2.6 cm enhancing mass at the left carotid bifurcation, consistent with a carotid body tumor (CBT). Scattered enhancing pulmonary nodules were also detected. Urine metanephrines and dopamine were normal. Results: Excisional biopsy revealed a paraganglioma with metastatis to an adjacent lymph node. The patient's spells had not recurred at 2 month's follow-up following resection. Conclusions: Paraganglioma is an uncommon neuroendocrine tumor, which when hormonally active can cause symptoms of hypertension and arrhythmia. In the case of this patient's hormonally inactive tumor, the patient's spells of symptomatic bradycardia were likely caused by traction on the carotid body by the tumor mass. This case's significance lies in its illumination of the pathophysiology of one cause of seizure-like spells associated with paroxysmal symptomatic bradycardia, its demonstration of the continued importance of a full physical exam, and in the rarity of the presentation. Funding: None