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Background
Reflex anoxic seizures (RAS) are predominantly seen in preschool children, and usually resolves by late childhood. In this case, however, RAS interestingly presented at an older age. With the appropriate workup and diagnosis, RAS can be successfully managed by controlling the underlying rhythm disorder. Additionally, this case points out that careful workup is needed on the part of neurologists, as anticonvulsants in this particular scenario may be harmful, and could expose patients to an unnecessary spectrum of side effects including cardiac arrhythmias.
Case presentation
A 61-year-old man with a medical history of dyslipidaemia and gastro-oesophageal reflux disease presented with sudden, repeated contractions of left upper arm and urine incontinence, followed by loss of consciousness for about 30s. He reported a similar episode occurred 2years earlier. Evaluation with echocardiography and Holter monitor at that time was unrevealing. This time, the patient and his wife stated that they were sitting watching TV and the wife noticed a strange look on his face; he was abnormally moving his arm, was profusely diaphoretic and became incontinent of urine. The patient thought he had drifted off to sleep. The patient denied having tongue bite, chest pain, shortness of breath, palpitations, headache or any focal signs of weakness.
His vital signs showed a temperature of 98.7°F, blood pressure of 105/78mm Hg, heart rate of 65 beats/ min and oxygen saturation of 98% on ambient air. On physical examination, patient was alert, awake and oriented. Head was normocephalic and atraumatic. Pupils were equal and reactive to light. Chest was clear to auscultation. Heart sounds were normal, with no rub, murmur or gallop. Abdomen was soft and non-tender. No peripheral oedema was detected.
Medication history: Ezetimibe-simvastatin 10-20mg daily and omeprazole 20mg daily.
Surgical history was significant for tonsillectomy at the age of 5.
Family history revealed that his mother had a pacemaker, his father had an open-heart surgery for unclear reason and his sister died of myocardial infarction in her 60s.
Social history was significant for current smoking and 45-pack-year smoking history. The patient uses approximately one pot of coffee daily. He denies any alcohol or drug use. He works on heavy equipment, and can conduct all of his daily activities without any limitation.
Investigations
Laboratory investigations, including complete blood count (CBC),...