The diagnosis and management of syncope in children and adolescents

Syncope in children and adolescents: Evaluation and treatment

Syncope in children is most often neurally mediated and usually has a natural history of spontaneous resolution or improvement. Syncope is defined as the temporary loss of consciousness resulting from a reversible disturbance of cerebral function. It is characterized by a loss of consciousness due to a lack of cerebral blood flow, rapid or sudden onset, falling of the patient, if not supported, and transiency of the attack. In children, it is most often benign, but may sometimes herald a more serious, potentially life-threatening cause. The main purpose of the present paper is to propose an evaluation scheme that will allow the physician involved in the care of children to differentiate the life-threatening causes of syncope with potential for injury or sudden death from the common, more benign neurally mediated syncope. Secondarily, the present article facilitates the identification of the patient with neurally mediated syncope who may benefit from medical therapy and distinguishes syncope from the more frequent noncardiac 'spells' of childhood.

Syncope associated with concurrent amitriptyline and fluconazole therapy

OBJECTIVE

To report on a 12-year-old white male with prostatic rhabdomyosarcoma who experienced episodes of syncope attributed to concurrent amitriptyline and fluconazole therapy, confirmed by readministration.

CASE REPORT

The patient began experiencing syncopal episodes periodically over a seven-month period. These repeated episodes occurred when fluconazole was administered for periodic mucositis secondary to chemotherapy. The patient had received fluconazole in the past with no difficulty and had been receiving a stable dose of amitriptyline for neuropathic pain. On discontinuation of amitriptyline, no further episodes were noted.

DISCUSSION

Concurrent administration of fluconazole with amitriptyline likely resulted in the decreased metabolism of amitriptytine. Three case reports presented in the literature of adults receiving concurrent amitriptyline and fluconazole have shown an increase in serum amitriptyline concentrations with concurrent administration of fluconazole; however, none of these patients were rechallenged. Literature available on amitriptyline overdose confirms that syncope and the adverse events noted in the case studies may result from elevated amitriptyline plasma concentrations.

CONCLUSIONS

The consistent presentation of syncope in our patient during readministration of amitriptytine and fluconazole strongly suggests a drug-drug interaction.