Diagnosis Under Pressure: An Unusual Case of
Orthostatic Hypotension
Michael Colacci, MD
1
, Florence Morriello, MD, MSc, FRCPC
2
1
Department of Medicine, University of Toronto, Toronto, ON, Canada;
2
Assistant Professor in the Department of Medicine, Northern Ontario School of Medicine, ON, Canada
Corresponding Author: Michael Colacci: michaelfcolacci@gmail.com
Received: 03 March 2020; Accepted: 03 April 2020; Published: 18 November 2020
DOI: http:dx.doi.org/10.22374/cjgim.v15i4.441
ABSTRACT
A 75-year-old man with a history of BPH and squamous cell carcinoma of the tongue, presented
to hospital with a one-month history of recurrent falls associated with orthostatic lightheadedness.
On initial examination he had a blood pressure (BP) of 132/75 and heart rate (HR) 86 while
supine and BP 101/54, HR 88 while standing. Physical exam revealed a left neck mass, and
computed tomography confirmed a large left nodal mass with encapsulation of the left carotid
artery. He was not a surgical candidate and had symptomatic improvement with midodrine
and fludrocortisone.This case highlights a unique cause of orthostatic hypotension due to
mechanical disruption of blood supply and autonomic innervation, and exemplifies the lack of
compensatory tachycardia with autonomic dysregulation.
RESUME
Un homme de 75 ans ayant des antécédents d’HBP et de ysregula spinocellulaire de la langue
s’est présenté à l’hôpital avec des antécédents d’un mois de chutes récurrentes associées à des
vertiges orthostatiques. Lors de l’examen initial, il avait une tension artérielle (BP) de 132/75 et
un rythme cardiaque (HR) de 86 en position couchée et une BP de 101/54, HR 88 en position
debout. En évaluant les causes communes, une tomographie informatisée de la tête/cou a révélé
une grande masse nodale gauche avec encapsulation de l’artère ysregu gauche. Il n’était pas un
candidat à la chirurgie et présentait une ysregulatio symptomatique grâce à la midodrine et à
la fludrocortisone. Ce cas met en ysregul une cause unique d’hypotension orthostatique due à
une perturbation mécanique de l’approvisionnement en sang et à une innervation autonome,
et illustre l’absence de tachycardie compensatoire avec ysregulation autonome.
Canadian Journal of General Internal Medicine
Volume 15, Issue 4, 2020 41
Case Report
CJGIM_4_WKBK.indd 41CJGIM_4_WKBK.indd 41 11/20/20 9:19 AM11/20/20 9:19 AM
Case Description
Mr. M, a 75-year-old gentleman with a history of benign
prostatic hyperplasia (BPH) and squamous cell carcinoma of
the tongue, presented to hospital with a 1-month history of
recurrent falls associated with orthostatic lightheadedness. His
medications were tamsulosin and morphine as needed. On
initial examination, he had a blood pressure (BP) of 132/75 and
heart rate (HR) 86 while supine and BP 101/54, HR 88 while
standing. On head and neck exam he was found to have a large
left neck mass which was solid and nontender, measuring 8 ×
10 cm. Cardiovascular, respiratory, and abdominal examination
were noncontributory. Extensive diagnostic workup ruled out
evidence of neurodegenerative disease, adrenal insufficiency,
or peripheral neuropathy. A CT head/neck was subsequently
performed, revealing a large left nodal mass with encapsulation
of the left carotid artery.
Initially, he was supported with aggressive intravenous fluid
administration and discontinuation of both tamsulosin and
morphine. A surgical consultation was obtained and given the
location of the left nodal mass, he was deemed not a surgical
candidate and conservative management was recommended.
Clinically, his orthostatic symptoms persisted, and a trial of
salt tablet replacement was started with some improvement of
symptoms, however, it was not until he was started on midodrine
and fludrocortisone that his orthostatic symptoms resolved.
Discussion
Orthostatic hypotension is defined as either an increase in HR
of ≥ 30 bpm, a decrease in systolic BP ≥ 20 mmHg or a decrease
in diastolic BP of ≥ 10 mmHg , within 3 min of standing from
a sitting or supine position.
1
The prevalence of orthostatic
hypotension increases with age, affecting 16% of people over 65
years old.
2
The most common etiologies include volume depletion,
autonomic and endocrine dysfunction, cardiovascular disease,
medications (predominately antihypertensives, antiadrenergics,
anticholinergics, and antidepressants), and alcohol.
1
Patients with
documented orthostatic hypotension should undergo a thorough
diagnostic workup including complete history and physical,
medication review, routine bloodwork, ECG, 24-h urine sodium
excretion, and autonomic function testing. Functional cardiac
evaluation and imaging should be considered in the appropriate
clinical context. In patients with a history of malignancy, carotid
bulb dysfunction due to mass compression, or previous radiation
remain important potential causes.
3
Treatment of orthostatic hypotension requires a multisystem
approach beginning with patient education on falls prevention,
dietician evaluation, and a slow taper of offending medications, if
necessary. If the patient does not have a history of cardiovascular
disease, salt tabs can be trialed. In patients who fail conservative
therapy, fludrocortisone, midodrine, droxidopa and pyridostigmine
have been shown to be effective.
4
This case highlights a unique
cause of orthostatic hypotension due to mechanical disruption
of blood supply and autonomic innervation, and exemplifies the
lack of compensatory tachycardia with autonomic dysregulation.
References
1. Lanier JB, Mote MB, Clay EC. Evaluation and management of orthostatic
hypotension. Am Fam Physician. 2011 Sep 1;84(5):527–36.
2. Rutan GH, Hermanson B, Bild DE, Kittner SJ, LaBaw F, Tell GS. Orthostatic
hypotension in older adults. The Cardiovascular Health Study. CHS
Collaborative Research Group. Hypertension. 1992 Jun;19(6 Pt 1):508. http://
dx.doi.org/10.1161/01.HYP.19.6.508
3. Sharabi Y, Dendi R, Holmes C, Goldstein DS. Baroreflex failure as a late
sequela of neck irradiation. Hypertension. 2003 Jul;42(1):110–16. http://
dx.doi.org/10.1161/01.HYP.0000077441.45309.08
4. Brignole M, Moya A, de Lange FJ, Deharo J-C, Elliott PM, Fanciulli A, et
al. 2018 ESC guidelines for the diagnosis and management of syncope. Eur
Heart J. 2018 Jun 1;39(21):1883–948. http://dx.doi.org/10.5603/KP.2018.0161
CJGIM_4_2019_172948.indd 49 11/8/19 12:18 PM
Dr Lindsay Melvin
Dr Tom Macmillan
Dr Wilson Kwong
Dr. Ameen Patel
Dr Dan Perri
Dr Rupal Shah
Dr. John You
Dr. Amol Verma
Dr. Walter Wodchis
Dr Johnathan Zipursky
Dr. Amna Ahmed
Dr. Shane Arishenkoff
Dr. Rodrigo Cavalcanti
Dr Kerstin De Wit
Dr. James Douketis
Dr. Bert Govig
Dr. Alya Kamani
Dr. Mitchell Levine
Dr. Irene Ma
Dr. Constance Mackenzie
Thank You To All Our 2020 Article Reviewers
Canadian Journal of General Internal Medicine
42 Volume 15, Issue 4, 2020
Colacci and Morriello
CJGIM_4_WKBK.indd 42CJGIM_4_WKBK.indd 42 11/20/20 9:19 AM11/20/20 9:19 AM
