12 year old girl--strange symptoms

[Sunshine614]

About a month ago, my normally healthy 12 year old niece had a strange thing occur.  As she was getting ready for school, she suddenly passed out or had a seizure (not sure which).  she went rigid and collapsed onto the floor.  she recovered and after standing for a few minutes, went rigid again and collapsed.  This time her eyes were rolled back and she stopped breathing.  by the time EMS arrived, she was concious again but did not remember the incident.  At the hospital, she was pale and her blood pressure seriously dropped but recovered a couple of times.  she was sent home after a couple of hours in the ER.  Since that day, we noticed both her pupils would suddenly dilate to the point that you couldn't see any iris.  Now, it is more common to see her pupils dilated than to see them normal.  She says she doesn't notice anything different and cannot tell that this is occurring.  She is also starting to feel fatigue and it is getting worse.  Her GP and a Neurologist are writing it off as body changes associated with puberty due to no negative test results.  I know puberty causes a myriad of different things in different children, but I just can't shake the feeling that this is something more.  Any suggestions?  

[Joyce K Lee, MD]

Dear Sunshine614,

Thank you for submitting your question.
I will answer your concerns to the best of my abilities, but please be informed that I am unable to offer a diagnosis based on your history and list of symptoms pertaining to your niece.
I am extremely limited in not having the opportunity to perform a full neurologic examination on your niece, nor am I able to review the pertinent imaging.
This is solely for educational purposes and should in no way be a substitute for a formal evaluation by a certified physician.

To begin, in reading your description of your niece's episodes, the first thing that crossed my mind was seizures -- particularly "drop attack seizures", more formally known as atonic seizures.
A person who has an atonic (or akinetic) seizure loses muscle tone. Sometimes it may affect only one part of the body so that, for instance, the jaw slackens and the head drops. At other times, the whole body may lose muscle tone, and the person can suddenly fall.

You did not go into detail about what type of work-up she has undergone, but if she hasn't had an EEG (which records brain wave activity) and an MRI of the brain these are good places to start.

THe fact that she has bilateral dilated pupils would go along with possible seizures, but other things should be considered as well -- in particular, illicit drug use (specifically LSD and cocaine) and other medical causes (e.g. central hypoventilation syndrome.)

Please don't be offended by my remarks of questioning possible drug use -- we ask each and all or our patients this question and I am in no way accusing your niece of illegal behavior.

I think that a formal opthalmologic evaluation would be appropriate as well.

Either way, be persistent -- I would not feel comfortable as a physician or an aunt in chalking it up to "puberty."  Medically, it doesn't make sense.

Thanks,
Hope this helps,
JKL, MD

[jcverive]

Doctors don't like to run a lot of tests on children unless they feel tests are absolutely necessary. Your niece's parents  may want to request an MRI on the basis that the test is non-invasive, does not require exported to potentially harmful X-Rays, and would provide a baseline MRI in the event of future such episodes.

[viktoriag]

Just a thought, has she recently had any vaccines? My friend's daughter had three episodes of fainting after receiving the meningitis vaccine, although she did have an MRI and all was normal. They think it may have been stress combined with other factors, and the vaccine was not really to blame.  However, strange that the first one happened in the office right after the shot.

I agree that an MRI is warranted. Has she seen a pediatric opthalmologist?