A 17-year-old previously healthy Caucasian female presents with recent history of syncope while rowing in open water. She fainted and fell out of her boat while rowing with her crew team. She reports that she usually rows in a 4- to 8-person boat, but on the day she passed out, she was rowing by herself and harder than usual. It was early morning, and she did not eat breakfast or drink anything prior to rowing. She felt a brief “flutter” in her chest for about 5 seconds, then got short of breath, and ended up in the water. She woke up underwater and does not remember how she got there. When she came to, it took about 5 minutes before the next boat reached her. She is taken to the local emergency room. The patient does not report any intercurrent illnesses or prior history of fainting. There is no family history of syncope or sudden death. At assessment, her vital signs are within normal limits. Her cardiac, pulmonary, abdominal, and neurological examinations are normal. Her EKG shows normal sinus rhythm with normal intervals and voltages. The QTc is normal (415 ms). Her echocardiogram is normal.

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Congratulations to Carlo B. Melini, MD, FAAP, of Marlton, New Jersey, who was first to correctly guess the answer to last issue’s challenge, neuropsychiatric systemic lupus erythematosus (NPSLE), the topic of this issue’s cover story.