Spells: In Search of a Cause

To determine the cause of spells, present clinical features, and discuss diagnostic approaches. Relevant medical literature is reviewed, and three illustrative cases are presented. Spells are a sudden onset of a symptom or symptoms that are stereotypic, self-limited, and recurrent. A spell involves both subjective perceptions and objective findings. In the assessment of patients who have spells, use of a systematic approach is important in determining the cause. The causes of spells include endocrine, cardiovascular, psychologic, pharmacologic, neurologic, and other miscellaneous disorders. A comprehensive history, physical examination, and basic laboratory studies are important in the initial assessment. Specialized testing is usually needed and directed by clinical suspicion based on the spell “phenotype” (for example, a pheochromocytoma, carcinoid syndrome, or mast cell disease) and the type of facial flush or pallor. In the assessment of the patient who has spells, the clinician should cast a wide but defensible diagnostic net. Initial studies should be directed by the clues obtained from the history and physical examination.