Patient with complete loss of consciousness (syncopal episode)

An 82-year-old lady with a history of osteoporosis, gastroesophageal reflux disease, lumbago, bilateral hip arthroplasty, hyperlipidemia and 2 hospitalizations for pneumonia in previous years, sought our help after an episode of "dizziness" that appeared in the bathroom while urinating a few hours after midnight. The patient denied the presence of any other symptoms, except a mild nausea and eructations (rales) which had been present for a long time and had not changed at all in the last few days. After clarifying questions, it emerged that the patient remembered entering the bathroom but not leaving it. The husband stressed that he had heard a noise and found his wife lying in the corridor between the bathroom and the bedroom but had not lost consciousness. The patient began to report that for the past few days she had been feeling weakness and easy tiredness, which forced her to significantly reduce her daily exercise.

On clinical examination there was a head injury, with no recollection of any blow in the previous hours or days, indicating a complete loss of consciousness. The neurological examination showed nothing abnormal, heart and lung auscultation as well as electrocardiogram were normal. On abdominal examination there was a cylindrical mass in the left abdomen with accompanying marked tenderness in the area. Although the occurrence of symptoms during urination in an elderly patient suggested vagotonic episode (i.e. the activation of a nerve that increases the motility of the bowel and urinary tract and significantly reduces the function of the heart leading to fainting), the presence of head trauma and abdominal tenderness required neurosurgical evaluation and further investigation and follow-up. Hospital admission was recommended.

A CT scan of the skull and brain was performed with findings commensurate with the patient's age. Blood tests showed an increase in white blood cell count with polymorphonucleosis, an increase in C reactive protein and red blood cell sedimentation rate (all suggesting the presence of inflammation). A urinalysis was done which showed many pyocytes and from the culture developed coliform (E. coli, urinary tract infection). A blood culture was taken which later tested positive for coliform. A CT scan of the abdomen showed diverticulitis (infection of the bowel wall) and thickening in the lower sections of the right lung (pneumonia). In the first hours of hospitalization and for 2 days he developed decadent febrile movement. The patient was put on double intravenous antibiotics. After a few days the patient had started to slowly regain her strength, remained unwell and was discharged from the hospital after 14 days of IV antibiotics due to the presence of the microbe in the blood (bacteremia) and the abdomen. On re-examination a few days later the patient reported that she had fully recovered her strength.

In this case it is difficult to distinguish whether the syncopal episode was due to the vagotonia or whether it was the result of infection in three organs of the human body (lungs, kidneys, intestines) and gradually increasing weakness. The presence of the microbe in the blood can explain how the microbe (coliform in this case, a microbe that colonizes our gut) was transferred to three different sites, a situation rare in patients with an intact immune system.