Episodes appear to be self-limited
In all patients, the episodes were self-limited. During the follow-up period, lasting an average of 18 months, none of the patients showed additional medical conditions—respiratory or otherwise—that could be linked to episodes of sigh syndrome. Recurrences of sighing episodes were reported by 24 subjects (60%) after the marker episode. One patient was diagnosed with carcinoma of the pancreas 2 years into follow-up, and later died.
Discussion
A benign, transient disorder
Aside from the solitary and unrelated death noted above, examination and follow-up in all 40 cases did not lead to an alternative diagnosis. Sigh syndrome thus seems to be an entirely benign and transient condition with no sequelae aside from possible recurrences.
Although the pathophysiology is unclear, our finding that 32.5% of patients had a recent traumatic incident strongly suggests a stress-related condition. Furthermore, 25% of the patients were already known to suffer from intermittent anxiety or somatoform disorders, although none were taking medications for these conditions. This adds support to the assumption that a mind-body interaction is underpinning the disorder. Large-scale migration, recent war or terrorist acts, or natural disaster are likely to increase the chances that the average physician will see a patient with sigh syndrome.
A tendency towards North African/Sephardic ethnicity, rather than European ethnicity—in addition to the cluster of 3 cases belonging to the same family—suggests the presentation may be a subconscious cultural, learned, or adopted expression of uneasiness.
Making your evaluation: History and physical are enough
The diagnostic evaluation of sigh syndrome—consisting of careful history-taking and a thorough physical examination—should be sufficient to differentiate it from an array of organic diseases. A physical examination is imperative to exclude other causes for this breathing abnormality.
Ancillary testing is rarely, if ever, indicated. It can perhaps be justified only if the condition is accompanied by an additional (if serendipitous) finding such as the cardiac murmur in the 7-year-old girl noted earlier. Physicians sometimes perform unnecessary investigations, being reluctant to base their diagnoses solely on their clinical expertise.9 A patient may interpret this testing as uncertainty or begin to doubt the diagnosis, thus augmenting—rather than reducing—any anxiety.10 The additional burden of the costs and possible side effects compound the futility of testing indiscriminately.11
Identifying these symptoms with the name “sigh syndrome,” and basing this diagnosis on the history and physical examination, stresses certainty and familiarity with the diagnosis.9 Not only does this reassure the patient, but it eases communication between professionals and forms a basis for research.
Management: Reassure your patient
Management of sigh syndrome consists largely of providing reassurances to your patient. You should emphasize that the condition is real, albeit benign, and that you understand the concern it causes.
Further treatment is unnecessary, aside perhaps from addressing any associated anxiety. A self-limiting (if sometimes recurrent) course can be confidently predicted, and follow-up visits can safely be left to the patient’s own discretion. Since the major correlation with sigh syndrome seems to be stress and the experience of a recent traumatic event, you should always investigate these 2 possibilities when taking the history of a patient with suspected sigh syndrome.
Acknowledgments
This work was inspired and developed by arthur Furst, MD, who died following the submission of this manuscript. Dr Furst was a distinguished and dedicated family physician, a thorough researcher, and a renowned tutor. We dedicate this article to the fond memory of a true leader in the field of rural medicine, and an exceptionally funny and amicable colleague.
Correspondence
Abby Naimer Sody, MD, Gush Katif Health Center, Neve Dekalim, Goosh Katif, Israel 79779; sodyna@clalit.org.il