Case Presentation: A 60-year-old man presented with several days of diarrhea, fevers, and syncope. Past medical history was significant for recurrent syncopal episodes, all of which occurred during febrile illnesses. Review of systems was negative for chest pain or other cardiac symptoms. His vital signs were normal except for a temperature of 39°C. ECG showed T-wave inversions in the right precordial leads and coved-type ST-elevation in leads V1 and V2. Initial troponin was 0.05 ng/mL (reference 0.00 – 0.03 ng/mL). Once the patient’s fever resolved, a repeat ECG showed resolution of the ST-elevations and T-wave inversions. Troponin peaked at 8.1 ng/dL, telemetry was normal for the remainder of his stay, TTE was within normal limits, and cardiac MRI showed subepicardial enhancement in the basal and apical inferior segments of the left ventricle. When stool culture grew Campylobacter jejuni, his troponin elevation and MRI findings were attributed to myocarditis. Given the patient’s history of recurrently syncope and transient ECG changes, a procainamide challenge was performed and confirmed the diagnosis of Brugada Syndrome. The patient underwent ICD placement and was referred for genetic counseling.
Discussion: The characteristic ECG changes seen in Brugada are a pseudo-right bundle branch block and one of two types of ST elevation in leads V1-V2; Type 1 pattern shows “coved-type” ST elevation, as in this case, while the elevations seen in Type 2 pattern are described as “saddle-back.” The ECG changes in Brugada can be transient and are known to be provoked by fever as well as prescription medications, illicit drugs, and alcohol. Patients with transient ECG changes consistent with a Brugada pattern should be evaluated further for medical history consistent with the clinical syndrome of Brugada and EP consultation should be considered as Brugada syndrome is associated with sudden cardiac death caused by polymorphic ventricular arrythmias. ICD implantation is indicated in most patients with Brugada syndrome, with select antiarrhythmics (amiodarone, quinidine) used as second-line treatment. Management of asymptomatic patients with Brugada pattern on ECG remains controversial however EPS can help risk stratify these patients. Given this patient’s recurrent history of syncope while febrile and the results of the Procainamide challenge, he was diagnosed with Brugada Syndrome rather than a phenocopy from his concurrent myocarditis, and ICD placement was indicated.
Conclusions: • Brugada syndrome is diagnosed when characteristic ECG changes are present along with symptoms such as syncope or sudden cardiac arrest.• The characteristic ECG changes of Brugada can be transient and are known to be provoked by fever, medications, drugs, and alcohol.
• Diagnosis of Brugada syndrome is an indication for ICD placement to prevent sudden cardiac death.