No Laughing Matter

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Perm J 2015 Winter; 19(1):94-95 [Full Citation]

https://doi.org/10.7812/TPP/14-128

Physicians, it is said, make the worst patients. Indeed, I have been accused of acting like the Black Knight in the movie Monty Python and Holy Grail, who after having his left arm deftly removed by King Arthur's sword examines his stump and protests, "'Tis but a scratch!"

A Coughing Man

Last year an upper respiratory tract illness swept through our household, hitting first my youngest son, then his older brother, and finally me. Only my wife was spared. We coughed for days and days. Still, we trudged on, my sons going off to school and I to work in the hospital. My wife, the only one in our family not burdened with a Y chromosome, looked at us one night at the dinner table and exclaimed, "You know, you all probably have whooping cough." What, I thought? We've all been vaccinated. It's not possible. ‘Tis but a cough.

All three of us had our nasal passages probed the following day. The results were as expected—meaning my wife (an Alpha Omega Alpha graduate of the University of Illinois School of Medicine) was right. I left work with a bottle of antibiotics in hand and the hope of a speedy recovery. What was in store for me, however, was so much more.

My cough slowly began to improve, but the three-week illness had, unbeknownst to me, taken a toll on my vocal cords. A week after I finished the antibiotics I went to bed one night with my health seemingly on the mend. A few hours into a deep sleep, suddenly, something woke me up. I remember being awakened by some sort of sensation, but for the first several seconds I had no idea what had disturbed my sleep. Then, it hit me—I couldn't breathe. I tried to breathe in. Nothing happened. I sat up and tried again. No air movement at all. I was, at this point, wide awake, and this new sensation had my full attention. I remember thinking to myself, "This isn't a good thing."

It's not a common practice for me to suddenly sit bolt upright in the bed in the middle of the night, and my deviation from the norm awakened my wife. Just as she sat up, I was able to get a small amount of air in my lungs, accompanied by a brief song of stridor. I stood up and began to slowly walk to the bathroom. I don't know why I went into the bathroom, but it just seemed like, if there was going to be some sort of medical drama, it should occur where there is white tile and bright lights. My wife, astutely, informed me she was going to call 911. "No," I signalled with my hands, "I'll be okay." I just needed to breathe. In what my wife later described as the longest three minutes of her life, I slowly began to get control of my breathing, and within about five minutes I was breathing normally. "See," I told her, "I was fine."

I had experienced sleep-related laryngospasm, as I learned from reading about my symptoms the next day. It was probably brought on my all my coughing and exacerbated by nocturnal gastroesophageal reflux. I assumed (because I have a Y chromosome) that it wouldn't happen again, but I was wrong. My wife, at that point, very kindly referred me to one of my medical group's otolaryngologists. I know that because I received a call from him that day, and he said, "Your wife told me I needed to see you." A proper medical plan was then put in place to decrease nocturnal gastroesophageal reflux and to decrease nocturnal laryngospams. Over the next month, I had only a couple of episodes of nocturnal laryngospasm, and I have been symptom free (off all treatment, as you might suspect from a compliant patient such as I) for the last eight months.

A Laughing Man

You might think I've learned nothing (I still, after all, have a Y chromosome) from my experience, but you'd be wrong. Four months ago while in New Zealand, a patient was referred to me because of syncope. He was a 43-year-old farmer (Mr XY) who had seen his GP (general practitioner), at the insistence of his wife because of syncope (it seems a Y chromosome is equally disadvantageous across the Pacific Ocean, just as having two X chromosomes seems to add some sort of common sense to life). His GP noted the patient had recurrent episodes of syncope during bouts of laughter and referred the patient to me for internal medicine consultation. I read the referral and wondered if the patient might have laughter-induced, or gelastic, syncope.

First described in 1997 in a patient who experienced syncope during laughter while watching the television show Seinfleld, and this was originally termed Seinfeld syncope.¹ Since then a number of other reports of laughter-induced syncope have surfaced, with etiologies ranging from benign causes (vasovagal syncope) to more serious (a cerebellar tumor).^2,3

Mr XY arrived at my office accompanied, and wisely so, by his wife. He had no significant past medical problems. His descriptions of the events which led to syncope were quite striking. The typical scenario was as follows: he would have a normal day and be at the pub later in the evening where he would have eaten a substantial meal and consumed several glasses of beer. After dinner, he would be talking with his friends and invariably the conversations would induce copious amounts of laughter. Sometimes, he said, after a bout of laughter he would feel a tightening in his throat and then it would be difficult to get air into his lungs. At times, if he relaxed and concentrated on his breathing the feeling would go away in a few seconds, but at other times the sensation would progress to the point where, literally, he couldn't get any air into his lungs. This was followed shortly thereafter by him passing out. He would awaken on the floor anywhere from 10 to 20 seconds later and be able to breathe just fine. He did not have any chest pain, headaches (unless he had hit his head on the way down, which he rarely did) loss of bowel or bladder control, or seizure activity.

Mr XY described these episodes so well I immediately recognized he was describing laryngospasm. It was easy for me to recognize, of course, because I had experienced the same sensation. Laryngospasm is often precipitated by gastroesophageal refleux disease and is a well-documented cause of syncope.⁴ I surmised Mr XY's large meal and several glasses of beer were contributors to the gastroesophageal reflux, and that his bouts of laughter likely increased the reflux, thus leading to laryngospasm. We discussed dietary and behavior changes to decrease gastroesophageal reflux, and he was prescribed omeprazole. In the 6 months since this intervention, he has had no further episodes of syncope.

A Patient's Story

There are enumerable ways to learn about diseases. Indeed, I have often commented on teaching rounds in the hospital that one way to accumulate knowledge of diseases would be to personally have every single disease known to man, and then it would be seemingly easy to recognize the symptoms in someone else. "Oh," you might say to a patient, "you're describing bitemporal hemianopsia. Yes, I had that in Autumn of 1997 when I was diagnosed with a pituitary tumor." It would be a Herculean feat, however, to have all those diseases, and the number of physicians willing to participate in the plan might be few. Barring having every single disease known to man, an individual physician is left to his/her own medical experiences, the medical experiences of his/her family, and very poignantly, the experiences of his/her patients. And that, I believe, is the teaching point. If we listen carefully to our patients' stories, they will tell us what we need to know. I'll just check with my wife to see if I'm right.

References

 1.    Cox SV, Eisenhauer AC, Hreib K. "Seinfeld syncope." Cathet Cardiovasc Diagn 1997 Oct;42(2):242. DOI: https://doi.org/10.1002/(SICI)1097-0304(199710)42:2%3C242::AID-CCD41%3E3.3.CO;2-5.
    2.    Famularo G, Corsi FM, Minisola G, De Simone C, Nicotra GC. Cerebellar tumor presenting with pathological laughter and gelastic syncope. Eur J Neurol 2007 Aug;14(8):940-3. DOI: https://doi.org/10.1111/j.1468-1331.2007.01784.x.
    3.    Kim AJ, Frishman WH. Laughter-induced syncope. Cardiol Rev 2012 Jul-Aug;20(4):194-6. DOI: https://doi.org/10.1097/CRD.0b013e31824c868f.
    4.    Maceri DR, Zim S. Laryngospasm: an atypical manifestaton of severe gastroesophageal reflux disease (GERD). Laryngoscope 2001 Nov;111(11

Pt 1):1976-9. DOI: https://doi.org/10.1097/00005537-200111000-00020.