CASE REPORT


https://doi.org/10.5005/jp-journals-10057-0220
Journal of Mahatma Gandhi University of Medical Sciences and Technology
Volume 7 | Issue 3 | Year 2022

Unmasking of Brugada Syndrome by Tropical Fever—An Unusual Presentation: A Case Report


Manish R Pahadia1, Puneet Rijhwani2https://orcid.org/0000-0002-9454-736X, Rajeev Sharma3, Komal Girdhar4, Ankita Tilala5, Abhinav Garg6

1,2,4,5Department of General Medicine, Mahatma Gandhi Medical College & Hospital, Jaipur, Rajasthan, India

3Department of Cardiology, Mahatma Gandhi Medical College & Hospital, Jaipur, Rajasthan, India

6Medical Department, Mahatma Gandhi Medical College & Hospital, Jaipur, Rajasthan, India

Corresponding Author: Komal Girdhar, Department of General Medicine, Mahatma Gandhi Medical College & Hospital, Jaipur, Rajasthan, India, Phone: +91 7683021101, e-mail: komalgirdhar2012@gmail.com

Received on: 10 May 2023; Accepted on: 13 June 2023; Published on: 16 September 2023

ABSTRACT

Introduction: Brugada syndrome is a rare inherited syndrome characterized by arrythmia leading to an increased risk of sudden cardiac death, despite a structurally normal heart. Diagnosis is based upon a specific ECG finding either spontaneously or after a sodium blocker test.Case description: We hereby report the case of a young male who presented to us with fever and chest pain which was initially evaluated on the lines of tropical fever but eventually lead to the diagnosis of Brugada Syndrome.Discussion: Brugada syndrome should be considered in young patients presenting with chest pain with ECG findings of ST elevation after differentiating it from Myocardial Infarction, which is its closest differential.Conclusion: Brugada syndrome is a diagnosis that requires high level of clinical suspicion. Since it can cause sudden cardiac death, a preventive intervention is required.Clinical significance: This case signifies the importance of differentiating ST elevation of Myocardial Ischaemia and Brugada syndrome. Since the management of both is different and prevention strategies need to be employed for Brugada syndrome.

How to cite this article: Pahadia MR, Rijhwani P, Sharma R, et al. Unmasking of Brugada Syndrome by Tropical Fever—An Unusual Presentation: A Case Report. J Mahatma Gandhi Univ Med Sci Tech 2022;7(3):95–97.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Keywords: Brugada syndrome, Case report, ST elevation, Sudden cardiac death

INTRODUCTION

The Brugada syndrome (BrS) is a conductional anomaly of the heart characterized by precordial ST elevation in V1–V3 leads with pseudo-right bundle branch block changes in the electrocardiogram (ECG), its hereditary bias and relation with a gene mutation affecting sodium channel function was established by Ramon Brugada in 1998.1

The typical ECG features are known to fluctuate,2 and are known to be revealed by several precipitants including febrile illness.3,4 This was a tropical sickness in our instance. It can be recognized by a malignant tachyarrhythmia in patients without obvious structural heart disease and an increased terminal QRS complex followed by a descending ST-segment elevation ending in a negative T wave in the right precordial leads.5 These tachyarrhythmias are potentially fatal, and patients frequently have a family history of sudden cardiac death. Drug-induced type 1 ECG may have a benign prognosis, whereas Brugada type 1 ECG has a known risk of tachyarrhythmias and sudden cardiac death.6 Although BrS prevalence has not been systematically assessed, it has been calculated that asymptomatic Brugada type 1 prevalence which is concealed by a history of fever, is higher than previously estimated.7

CASE DESCRIPTION

We are reporting a case of a 32-year-old previously asymptomatic male presenting with a 4-day history of fever, abdominal pain, headache, and generalized body ache. He reported to the outdoor department and was admitted. On the next day, he developed sudden onset chest pain while febrile and his ECG showed ST elevations in V1—3 chest leads with secondary ST-T changes in other leads. An anterior wall myocardial infarction was suspected for which an urgent coronary angiography was performed which was normal. His serum creatinine levels were 7.4 mg/dL a nephrology opinion was taken to rule out chronic kidney disease. His scrub immunoglobulin M came out to be positive. He was treated with doxycycline 100 mg BD for scrub typhus. As his serum calcium, phosphorus, and parathyroid came out to be in the normal range with normal corticomedullary differentiation in ultrasonography, chronic kidney disease was ruled out.

Considering the typical ECG changes, a diagnosis of BrS was considered. Since the patient gave negative consent for sodium channel SCN5A and SCN10, a mutation study, a clinical diagnosis of BrS was established. At the time of discharge, the patient was discharged on day 10 with a normal complete blood count, serum electrolytes level, and C-reactive protein, with the same persistent ECG changes. The patient was also advised prophylactic β-blocker therapy with implantable cardioverter-defibrillator.

DISCUSSION

Brugada syndrome (BrS) is a rare arrhythmogenic causing sudden cardiac death. It has a global prevalence rate of 0.5 per thousand.8 There are three distinct ECG–BrS patterns. A negative T wave is followed by an ST-segment elevation of around 2 mm that is downsloping or cove-shaped. Type 2 has a positive T wave that gives the impression of a saddleback and an ST elevation of around 2 mm at the ST-segment’s terminal part. Type 3 may feature an ST-segment elevation with a coved shape or saddleback shape and a terminal elevation of <1 mm (Fig. 1).

Fig. 1: Electrocardiogram (ECG) findings (I)

SCN5A is known to be a temperature-sensitive sodium gating channel and hence a possible link between febrile illnesses and BrS is probable. Until now Brugada ECG pattern has been documented in the context of a febrile illness such as pneumonia, bacteremia, viral infections, gastrointestinal infections, and mastitis, our case is different from unmasked Brugada pattern in scrub typhus.

Cardiac manifestations of tropical diseases such as shortening of QT interval and type 1 atrioventricular block are well known. However, the relationship of BrS with tropical fever is not well documented. Hence ST-T changes in the background of tropical fever should always raise suspicion of BrS since the management is very different (Fig. 2).

Fig. 2: Electrocardiogram (ECG) findings (II)

CONCLUSION

In a country like India where facilities are not available at par, the diagnosis of Brugada is difficult. Diagnosis of Brugada in a case of tropical fever that has high prevalence should always be considered since the risk of sudden cardiac death is associated with it and hence requires appropriate therapy timely and lifelong.

ORCID

Puneet Rijhwani https://orcid.org/0000-0002-9454-736X

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