Brugada syndrome unmasked by fever

¹Department of Internal Medicine, International Medical University, Clinical Campus Kluang, Kluang, Johor, Malaysia

^&Corresponding author
Yong Khai Pang, Department of Internal Medicine, International Medical University, Clinical Campus Kluang, Kluang, Johor, Malaysia

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A 32-year-old man presented with high fever, cough and sore throat. He was seen on the second day of his febrile illness after he experienced a “fainting spell”. He felt thumping in his chest and then fell into unconsciousness. Minutes later, he recovered spontaneously. His elder brother, aged 35 years had died of a “fast irregular heart rhythm”. Physical examination was unremarkable and his temperature was 39°C. An Electrocardiogram (ECG) was taken. The ECG manifests Brugada type 1 coved pattern in V1-V3 (A,B). There is a pseudo-right bundle branch block. At the end of QRS, there is an ST-segment elevation (STE) of ≥2mm in V1 and V2. The STE is followed immediately by an oblique rectilinear downsloping ST which terminates in a small T wave inversion. Serial ECGs over 4 days showed reversal of abnormalities with defervescence. On Day 3 (C), the temperature fell to 37.7°C and the Brugada type 1 coved pattern had evolved to the type 2 saddleback pattern. On the fifth and sixth day of his illness (D,E), the right precordial leads had normal morphology. Cardiac enzymes and electrolytes were normal. The history of a fever induced Brugada type 1 coved pattern, a probable syncope, a brother who died of a tachyarrhythmia, the reversal of ECG abnormalities with defervescence pointed to the diagnosis of Brugada Syndrome. The patient was referred to the National Heart Centre where the diagnosis was confirmed and an automatic implantable cardiac defibrillator was implanted.

Figure 1: (A) 12 lead ECG of patient. Leads V1 to V3 manifests Brugada type 1 coved pattern, pseudo-right bundle branch block, ST segment elevation of > 2mm; (B) day 2, temperature 39�C; (C) day 3, temperature 37.7�C. ECG was not taken on day 4. (D) day 5, temperature 37.1�C; (E) day 6, temperature 36.9�C. B-E leads V1 to V3 show Brugada type 1 coved pattern that reverses with defervescence