A Rare Case of Dual Syncope, Vagal and Psychogenic Mechanism, Elucidated by a Head-Up Tilt Test (HUTT)

A 51-year-old woman, with congenital inability to hear and speak, came with recurrent episodes of syncope. The syncope was unheralded (without warning) on most occasions. It was not associated with nausea, vomiting, cold sweats. It was sudden in onset and was often triggered by emotional stress. There was a history of the recent demise of three siblings in short succession. The syncope was in the upright as well as while supine positions. The examination was unremarkable with a normal orthostatic response. All basic laboratory investigations were normal. The electrocardiogram showed partial right bundle branch block while the echocardiogram revealed a normally functioning heart. Head-up tilt testing revealed two episodes of syncope in the same test, with the first syncope during the plain tilt with normal blood pressure and heart rate and spontaneous recovery, while tilt was continued at 70 degrees. The second syncope occurred with nitrate provocation, with typical neurocardiogenic response (predominantly vasodilatory). The patient became incontinent for urine and experienced myoclonic jerks. The diagnosis of psychogenic pseudosyncope and neurocardiogenic syncope was confirmed on the tilt test.