Syncope and COVID-19: Case series and literature review

Ibrahim A Alranini; Tarek S Kashour; Ahmed S Al-Hersi; Wael A Alqarawi

doi:10.4103/jnsm.jnsm_134_21

CASE SERIES AND LITERATURE REVIEW

Year : 2022 | Volume : 5 | Issue : 3 | Page : 204-209

Syncope and COVID-19: Case series and literature review

Ibrahim A Alranini, Tarek S Kashour, Ahmed S Al-Hersi, Wael A Alqarawi
Department of Cardiac Sciences, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission	17-Oct-2021
Date of Decision	10-Jan-2022
Date of Acceptance	24-Feb-2022
Date of Web Publication	08-Jul-2022

Correspondence Address:
Ibrahim A Alranini
Department of Cardiac Sciences, College of Medicine, King Saud University, Riyadh
Saudi Arabia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsm.jnsm_134_21

Abstract

COVID-19 infection can present with atypical symptoms such as syncope. We reported 2 patients who presented to our emergency department with syncope as a chief complaint. One patient did not have any other symptoms while the other patient developed severe pneumonia later during hospitalization. The cardiac workup including electrocardiogram, cardiac monitoring, and echocardiogram were unremarkable. Both patients were diagnosed with neurally mediated/reflex syncope secondary to COVID-19. No recurrence was reported during follow-up. We then performed a literature review and described previous cases focusing on clinical presentation and the likely mechanism of syncope.

Keywords: COVID-19, neurally mediated, pneumonia, syncope

How to cite this article:
Alranini IA, Kashour TS, Al-Hersi AS, Alqarawi WA. Syncope and COVID-19: Case series and literature review. J Nat Sci Med 2022;5:204-9

How to cite this URL:
Alranini IA, Kashour TS, Al-Hersi AS, Alqarawi WA. Syncope and COVID-19: Case series and literature review. J Nat Sci Med [serial online] 2022 [cited 2022 Aug 17];5:204-9. Available from: https://www.jnsmonline.org/text.asp?2022/5/3/204/350295

Introduction

The ongoing coronavirus disease (COVID-19) pandemic is a devastating health problem that has affected millions of people worldwide.^[1] The disease has different presentations ranging from no symptoms to severe and life-threatening conditions.^[2],[3],[4] The most common presenting symptoms are cough, fever, myalgia, and dyspnea.^[4],[5] Syncope has been reported to be one of the infrequent symptoms which can be the only presenting symptom or associated with other common symptoms such as fever and dyspnea.^[6],[7],[8] Although there is no clear explanation for the mechanism of COVID-19-related syncope, multiple potential pathophysiological mechanisms such as reflex syncope, orthostatic hypotension, and arrhythmic syncope have been proposed.^[9] Here, we reported two patients who presented to our emergency department with syncope as a presenting symptom of COVID-19.

Case 1

A 60-year-old gentleman with no significant past medical history presented to the emergency department with two episodes of syncope. The first one happened in the bathroom during micturition where he felt dizzy for a few seconds then lost consciousness. The second attack occurred a day later after waking up from sleep and standing where he suddenly lost consciousness and fell down on his face. In both occasions, he felt completely fine after regaining consciousness apart from pain and small wound on his forehead after the second episode. Upon presentation, he did not report any other symptoms. Physical examination revealed a small forehead hematoma and laceration but otherwise, was unremarkable. Of note, his orthostatic vital signs were normal. Computed tomography (CT) of the brain showed small subgaleal hematoma which was assessed by the neurosurgery team and did not require any intervention. Apart from mild lymphopenia, other laboratory investigations were normal. Electrocardiogram (ECG), chest X-ray, and transthoracic echocardziography (TTE) were all normal. He was admitted to a telemetry bed. Nasopharyngeal swab was taken as a routine work up for any hospitalized patient which came back positive. On the 2^nd day of hospitalization, he developed fever (38.5°C) but otherwise remained asymptomatic. Another syncopal attack occurred on the 4^th day of hospitalization after he stood up from his bed where he lost consciousness and fell to the floor. Review of his telemetry recordings revealed slowing of the heart rate from 80 to 60 beats/min just before the event. He was discharged in stable condition. During follow-up in the clinic, he did not reported any further syncopal episodes.

Case 2

A 50-year-old male patient who is known to have celiac disease and obstructive sleep apnea on home continuous positive pressure ventilation presented to our hospital with a 2-day history of fever associated with two syncopal attacks. The first syncopal episode occurred in the bathroom after getting up from the toilet and walking for a few steps. The second attack occurred a day later while he was walking at home where he lost consciousness and fell down. In both occasions, he did not report any other symptoms. Upon presentation, his oxygen saturation was 88% on room air, but the rest of physical examination was unremarkable. His laboratory work up was significant for mild anemia, lymphopenia, and thrombocytopenia. Echo and ECG [Figure 1] were normal. The nasopharyngeal swab result was positive for COVID-19. His chest X-ray showed diffuse bilateral infiltrates and his CT chest was consistent with COVID-19 disease [Figure 2]. During the 3^rd day of hospitalization, he started to have progressive shortness of breath and became more hypoxic for which he required intermittent noninvasive positive pressure ventilation. He received oral steroids, tocilizumab, and remdesivir and improved gradually until he was discharged in a stable condition. During follow-up, no other syncopal attacks experienced after recovery.

Figure 1: The electrocardiogram for the second patient

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Figure 2: The chest X-ray (a) and computed tomography chest for the second patient (b)

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Discussion

Syncope is a frequently encountered problem in the emergency department that has a wide differential diagnosis. Patients with syncope can be discharged from the emergency department and worked up in an outpatient sitting if the history is suggestive of a benign cause such as vasovagal or orthostatic syncope.^[10] However, syncope has been reported to be one of the uncommon presentations for COVID-19 with an incidence ranging from 3.7% to 7.1%.^[8],[9] There is no single clear pathophysiological mechanism that could explain syncope in patients with COVID-19; instead, a variety of mechanisms has been proposed ranging from benign causes like reflex syncope to more serious mechanisms such as arrhythmic syncope.^[8],[9],[11]

A review of literature revealed 17 relevant publications describing syncope in COVID-19 patients [Table 1]. Patients presented with syncope either as an isolated presenting symptom or associated with classic symptoms such as cough, fever, and shortness of breath. Similar to our patients, neurally mediated/reflex syncope was the likely mechanism of syncope in the majority of the reported cases. This is supported by slowing of the heart rate just before losing consciousness when patients are monitored as documented in our first patient. No clear correlation between the presence of syncope and the disease severity has been reported, as some patient-reported syncope in ICU sitting while some other patients had mild disease or even no other symptoms. Our first patient had a very mild disease while the second patient required ICU admission. It is not clear, however, how the virus causes this imbalance between sympathetic and parasympathetic activities. One of the proposed mechanisms indicates that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could have caused angiotensin-converting enzyme-2 receptor internalization in the nucleus of the solitary tract and other midbrain nuclei, impairing baroreflex and chemoreceptor response, and inhibiting the compensatory tachycardia during acute hypocapnic hypoxemia.^[6] Notably, a significant number of patients had abnormal chest images associated with hypoxia. This may indicate that hypoxia could be one of the aggravating factors for autonomic dysfunction in COVID-19 patients. Long-term follow-up for the patients is needed to assess the patient's response after recovery. Other possible mechanisms of syncope in COVID-19 disease include arrhythmic syncope due to transient heart block,^[12] sinus node dysfunction,^[13] and possibly Burgada syndrome.^[11],[14]

Table 1: Summarizes the review of literature which showed 17 relevant publications describing syncope in COVID-19 patients

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One wonders whether syncope reported with COVID-19 is related to the viral illness causing dysautonomia in general or associated specifically with COVID-19. Interestingly, syncope has been reported in association with influenza virus with prevalence of 2.2%.^[26],[27] The total number of the reported patients were 15 patients. One patient developed sinus node dysfunction while 3 patients found to have dysautonomia. This may indicate that the mechanism of syncope in patients with COVID-19 is not specifically related to this virus (SARS-COV-2) and might be a part of dysautonomia caused by many viral illnesses. A possible explanation for why syncope was described with COVID-19 more than any other viral infection is the massive screening for COVID-19 regardless of symptoms which might have led to incidental finding of COVID-19, especially in patients who presented with frequently encountered symptoms such as syncope. In other words, syncope and COVID-19 might be present together just because they are prevalent in the community. A systematic study comparing the incidence of syncope in COVID-19 compared with other viruses is needed to ascertain whether syncope is truly associated with COVID-19 or not.

In summary, we reported 2 cases of syncope in patients with COVID-19 and provided a literature review pertaining to proposed mechanisms of syncope in COVID-19 patients. We believe that the likely underlying mechanism for syncope in our patients is neurally mediated/reflex syncope where there is an imbalance between sympathetic and parasympathetic activity. This is in line with most of the previously reported cases. The main limitation of the literature is the lack of systematic studies comparing the incidence of syncope in COVID-19 to other viral illnesses and the difficulty ascertaining the mechanism of syncope. Future studies to examine the autonomic function in patients with syncope and COVID-19 are needed to explore the role COVID-19 in the pathophysiology of syncope in these patients.

Conclusion

Syncope can be the only presenting symptom of COVID-19. Neurally mediated/reflex syncope where there is an imbalance between sympathetic and parasympathetic activity contributed to the majority of syncopal events in the reported cases. Observation with clinical follow-up appears to be a safe approach to these patients, once other mechanisms of syncope have been ruled out.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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