A 23‐year‐old man had fever and palpitation on the second day following uncomplicated laparoscopic appendectomy. His medical history was significant for rheumatoid arthritis, which was well controlled with methotrexate and folic acid. Family history was not significant. On examination, temperature was 102.30°F, pulse was 120/minute, respiratory rate was 19/minute, and blood pressure was 104/70 mm Hg. Physical examination was normal. Bedside 12‐lead EKG revealed sinus tachycardia with ST‐segment elevation in leads V1–V3 with incomplete right bundle branch block. ASA 325 mg was given. Troponin I level was <0.06 ng/mL, and CK‐MB was 0.7 ng/mL. CBC, CMP, and D‐dimer were within normal limits. Patient was transferred to CCU and treated with IV fluid, antibiotics, ASA, and Tylenol. CT chest, abdomen, and pelvis was unremarkable. Transthoracic echocardiogram did not reveal structural and functional abnormalities of heart. Repeat cardiac enzymes were normal . Patient became afebrile on the following day, and repeat EKG showed normal sinus rhythm with complete resolution of ST elevation, a diagnosis consistent with Brugada syndrome. Education was provided, and patient was instructed to manage precipitating conditions for Brugada syndrome, including use of ASA during fever. He was discharged home in a stable condition on day 5. Subsequent follow‐up evaluations in 4 weeks and 3 months were unremarkable.
Brugada syndrome is an autosomal dominant disorder of heart resulting from mutation in the sodium channel gene, which is characterized by typical EKG pattern of ST‐segment elevation in leads V1–V3 and incomplete or complete right bundle branch block usually in absence of identifiable structural heart diseases. Brugada syndrome is often asymptomatic but frequently associated with syncope, life‐threatening ventricular arrhythmia, and sudden cardiac death. Asymptomatic and dormant Brugada syndromes can be unmasked by multiple factors like fever, ischemia, or medications, which is illustrated in the case. Also highlighted in the vignette is that EKG should be carefully evaluated because ST‐segment elevation in atypical circumstances is suggestive of etiology other than STEMI. Considering the life‐threatening nature, Brugada syndrome should always be suspected in patients with sudden cardiac death, ventricular arrhythmia, and unexplained syncope, and appropriate workup including imaging, electrophysiological study or pharmacological challenge test is warranted to establish the diagnosis. Once diagnosed, implantation of ICD is recommended in symptomatic patients or asymptomatic Brugada syndrome with positive family history of sudden cardiac death. In contrast, asymptomatic patients with no family history of sudden cardiac death can be managed conservatively with close follow‐up, and ICD implantation is not recommended. However, prompt management of precipitating events like fever, hypothermia, or infections is essential to prevent complications.
Brugada syndrome should be one of the differentials of ST‐segment elevation.