HISTORY: A 36 year old previously healthy male presented to the medical tent via wheelchair with acute onset of dizziness and nausea after finishing a marathon. He had met his goal of finishing just under 3 hours. He alternated water and sports drinks for fluid replacement. He described the dizziness as a spinning sensation that began shortly after crossing the finish line associated with emesis. This persisted while lying still with his eyes closed. Symptoms were exacerbated by tilting his head or attempting to look up. No lightheadedness, chest pain, shortness of breath, hearing changes, numbness or altered mental status. No history of vertigo episodes, recent illness or head trauma. In the medical tent, he vomited 3 times. He was laid supine with his legs elevated. Over 45 minutes, he had 5 cups of oral electrolyte replacement, 3 cups of water and a banana without improvement. He was eventually able to walk one lap around the medical tent while keeping his gaze focused downwards.
PHYSICAL EXAMINATION:
T 0 min:
BP 120/58, HR 94, RR 19, O2 94%
T 45 min:
Supine BP 116/64, HR 63
Standing BP 105/60, HR 72
Rectal temp 97.9F
He was mildly ill-appearing with clear mental status, alert and oriented x 4. Cranial nerves II-XII were intact and he demonstrated 5/5 strength in b/l upper and lower extremities. Extraocular movements and smooth pursuit were normal. No signs of spontaneous nystagmus. Nystagmus was observed with change in posture from sitting to supine to side lie. Head impulse testing was positive for compensatory saccade response. Dix-Hallpike maneuver to the right was positive for nystagmus and reproduction of symptoms.
DIFFERENTIAL DIAGNOSIS:
1. Exercise associated postural hypotension
2. Exertional Heat Stroke
3. Exercise Associated Hyponatremia
4. Vestibular system dysfunction
5. Central nervous system lesion
TESTS AND RESULTS:
N/A
FINAL/WORKING DIAGNOSIS:
Benign paroxysmal positional vertigo (BPPV)
TREATMENT AND OUTCOMES:
1. The Epley maneuver was performed, inducing one episode of emesis followed by gradual improvement of symptoms over the following 10 minutes.
2. Instructed to avoid rapid or frequent head movements for the next few days.
3. Gradual return to running after complete resolution of symptoms.
4. Follow up with primary care for any worsening of symptoms.