Case 1: Syncope in a 16-year-old Girl

Presentation

A previously healthy 16-year-old girl is transferred from a referring facility for syncope and altered mental status. The previous day, she received the meningococcal vaccine. After a stressful conversation with her father, she began to complain of chest pain, diaphoresis, and nausea. She vomited, became clammy, and fell to the ground unresponsive. She was brought to the referring facility, where she was given epinephrine, diphenhydramine, methylprednisolone, famotidine, and 4 L of isotonic fluids for a possible anaphylactic reaction to the vaccine. She remained groggy, tachycardic, and anuric.

After transfer, her vital signs are as follows: temperature, 97.5ºF (36.4ºC); heart rate, 120 beats/min; respiratory rate, 23 breaths/min; blood pressure, 95/44 mm Hg; and oxygen saturation, 98% on room air. On physical examination, she is sleepy but responsive, with a Glasgow Coma Scale score of 15, delayed capillary refill, 2+ pulses, and hepatomegaly to 4 cm below the costal margin. The remainder of her examination findings are within normal limits.

She denies pain, fevers, night sweats, unintended weight loss, exercise intolerance, or peripheral edema. She reports a similar episode during final exams during her previous school semester that …