Case presentation
A 26-year- old age male patient presented to our medical facility with a history of multiple episodes of fainting scattered throughout the previous year. Upon further inquiry, the patient mentioned that they had experienced three episodes of fainting within a period of one year. On examination, her pulse was at 40/min with an irregular rhythm. Her blood pressure (BP) reading registered as 140/90 mmHg. The cardiovascular system examination showed no abnormalities. Further investigations showed that the full blood count and sugar levels were in the normal range. Additionally, the kidney function tests, serum electrolytes and liver tests all yielded normal results. The electrocardiography (ECG) results showed the presence of sinus node arrest accompanied by a junctional escape that was recorded at a rate of 35 to 40 beats per minute (Figure 1). Holter monitoring was performed to verify the diagnosis and identify any presence of AV blockage or alternate rhythm disturbances that might result in syncope. The test results confirmed Sick Sinus Syndrome, which showed pauses and arrest in sinus rhythm along with junctional escape beats/rhythm (Figure 2). An ultrasonography revealed a midline liver that was more towards the left side, with a leftward hilum and normal hepatic veins and inferior vena cava on the right side. Additionally, no spleen was identified on the left side, in accordance with situs ambiguous abdominis. Echocardiography revealed normal left ventricular ejection fraction and no congenital heart defects. An HRCT chest with upper abdomen was conducted on a 128-slice dual source dual energy scanner. The scan results revealed the presence of liver on the left side of the abdomen and in the midline stomach. (Figure 3A). The abdomen contained numerous accessory spleens, at least 7. A bilateral trilobed lung with hyparterial bronchus is seen (Figure 3B). Situs ambiguous with polysplenia syndrome was diagnosed on CT. (Figure 3C). The patient received a DDDR (dual-pacing dual-sensing dual-response rate-adaptive) pacemaker for sinus node dysfunction. The patient responded well, with improvement in symptoms and findings at follow-up.