Holter monitoring revealed significant rhythm disorders leading to the diagnosis of sick sinus syndrome in a 13-year-old boy previously misdiagnosed with PNES.
Prolonged ambulatory ECG monitoring is crucial for identifying underlying cardiac etiologies like sick sinus syndrome in pediatric patients presenting with syncope or seizure-like events.
Background: Sick sinus syndrome (SSS) is an uncommon cardiac conduction disorder in children. This typically presents a diagnostic challenge due to its nonspecific nature and similarity to neurological diseases. Case presentation: We present a 13-year-old boy with recurrent episodes of syncope, seizure, palpitation, headache, and generalized fatigue. In the beginning, he did have a normal baseline electrocardiogram (ECG), so he was addressed as a case of psychogenic nonepileptic seizures (PNES) and started on Escitalopram. However, his symptoms persisted with treatment, and he was reevaluated. Subsequent ECGs demonstrated sinus bradycardia and atrial fibrillation. The 48-hour Holter monitoring showed significant rhythm disorders with tachycardia–bradycardia syndrome, finally leading to the diagnosis of SSS. The echo showed mild mitral valve prolapse with trace regurgitation. The patient initially was given salbutamol and aminophylline for acute symptomatic relief, but he was sent for permanent atrial pacemaker implantation due to the possibility of repeated syncopal episodes. Discussion: SSS is underappreciated in the pediatric population, being obscured by other frequent conditions, such as neurological and psychiatric disorders. The lack of specific signs, such as syncope and seizure-like events, can mislead physicians with subsequent delays in treatment. In our patient, the failure to recognize the epilepsy and the initial misdiagnosis as PNES are characteristics of this diagnostic challenge. The turning point occurred with the institution of extended Holter monitoring, which revealed profound rhythm disturbances and enabled early detection of the cardiac disease. Conclusion: This case highlights the importance of considering cardiac etiologies when evaluating pediatric patients with syncope and/or seizures, and contributes to the growing body of evidence supporting the value of prolonged ambulatory ECG (Holter) monitoring, particularly when initial ECGs are standard. It also reinforces the importance of early recognition in preventing disease-related complications and optimizing quality of life.
Mujtaba et al. (Tue,) reported a other. Holter monitoring revealed significant rhythm disorders leading to the diagnosis of sick sinus syndrome in a 13-year-old boy previously misdiagnosed with PNES.
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