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BACKGROUND
Syncope and palpitations were recognised by Lancisi and Albertini as distinctive cardiological symptoms (conmotio cordis and palpitatio cordis, respectively) as early as the 18th century. 1 Furthermore, pallor of the face and loss of consciousness were among the first phenomena that were identified to occur in the context of an epileptic seizure. Hence in 1856, writing on epilepsy, cosmopolitan neurologist Brown-Séquard realised the difficulties in the differential diagnosis, stating that "the brain proper loses at once its functions, just as it does in a complete syncope". 2
Nowadays, distinguishing between epileptic seizures and syncope still presents a daily challenge for cardiologists and neurologists. Long Q-T syndrome and hypertrophic cardiomyopathy (HCM) are two hereditary arrhythmogenic heart conditions typically leading to recurrent syncope in early adulthood and both can, as a consequence, be mistaken for epilepsy. Because of the significantly increased risk of sudden cardiac death (SCD) associated with both diseases, 3 a prompt and accurate diagnosis is of paramount importance. Therefore, the clinical history remains a basic but nonetheless crucial instrument in guiding us through to the right diagnosis.
CASE PRESENTATION
We report the cases of two patients with long Q-T syndrome and HCM, respectively, who were reassessed for recurrent transient loss of consciousness (TLOC) and convulsions in spite of treatment. One patient, a 40-year-old female, who had been diagnosed with epilepsy in her teens and in whom phenytoin had been prescribed and whose sister was being investigated for heart rhythm problems, was admitted to casualty following a TLOC. A year prior to admission she was rescued from a swimming pool with an aborted cardiac arrest. Six months later, during her father's funeral she had another episode accompanied by "snow-white" pallor and generalised myoclonic jerks but without tongue biting or post-ictal confusion.
A 30-year-old male with HCM whose brother was known to have obstructive HCM, had a cardioverter-defibrillator implanted. This decision was mainly based on the assumption that he was having recurrent cardiogenic syncope. Despite this, he repeatedly presented to casualty with TLOC. He described paroxysmal stereotyped experiential phenomena and complex auditory hallucinations consisting of loud familiar music sometimes leading to secondarily generalised tonic-clonic seizures with lateral tongue biting, prolonged post-ictal confusion and complete memory loss for over half an hour following the seizure.
INVESTIGATIONS