Fever-induced Brugada Syndrome

Dr. K. Ilakkia Meena1, Dr. P. Vijay Shekar2,*

1Medical Officer, Kauvery Heart City, Trichy

2Consultant Cardiologist and Electrophysiologist, Kauvery Heart City, Trichy

*Correspondence: Tel.: + 91 96864 69004; email: [email protected]

Case Presentation

A 70-years-aged male patient, known to have diabetes, presented with complaints of fever, and cough for 3 days, followed by an episode of syncope.

The patient was evaluated elsewhere during which ECG showed ST elevation in V1 and V2. The patient was diagnosed with Acute Myocardial infarction (AMI) and referred for further management.

xOn admission, the patient was conscious and oriented; vitals showed blood pressure of 100/80 mm Hg, and heart rate was 130 bpm. High-grade fever (102 °F) was recorded at the time of admission. A repeat ECG showed persistent ST elevation in V1 and V2 (Fig. 1).

Fever-induced Brugada

Fig. 1. 12 lead Electrocardiogram during fever: Type 1 Brugada pattern characterized by ST elevation in V1 and V2.

Cardiac enzymes were negative and a bedside transthoracic echocardiogram revealed no abnormality.

The patient was treated with intravenous fluids, anti-pyretics and antibiotics.

Lab investigation revealed elevated white blood cell count. CT chest revealed right middle lobe and left basal atelectasis. Repeat ECG (Fig. 2), a day later showed resolution of ST changes. Coronary Angiogram was done to confirm the absence of coronary artery disease which revealed normal coronaries. Hence, a final diagnosis of fever induced Brugada Syndrome was made.

Fever-induced Brugada1

Fig. 2. 12 lead electrocardiograms after resolution of fever. Complete resolution of ST changes.

Discussion

Brugada Syndrome is a rare genetic disorder with an autosomal dominant pattern of inheritance. Characterized by the presence of sodium channel (SCN5A) mutations, it is an important cause of sudden cardiac death, especially in young individuals. Brugada syndrome can be identified by typical ECG patterns. There are 3 types of ECG patterns: Type 1: Coved ST elevation > 2 mm with T inversion in V1V2, Type 2: Saddleback ST > 2 mm with terminal ST elevation > 1 mm , Type 3 is similar to type 2 with terminal ST elevation < 1 mm. A spontaneous Type 1 pattern is associated with higher clinical event rates. A Brugada pattern ECG can be unmasked by various triggers such as fever, drugs, ischemia, dehydration, etc [1].

“Fever-induced Brugada” is a recognized entity [2], where development of fever triggers an ECG pattern or clinical symptoms, consistent with Brugada syndrome. Expression studies performed by Dumaine et al [3] with mutant cardiac sodium channels demonstrated worsening of the biophysical properties of the defective channels at higher temperatures, leading to further loss of function of sodium channel current and characteristic ECG patterns. However, the clinical significance and long-term outcomes of this subset of patients remain unclear.

In our patient, ECG showed a characteristic Type 1 pattern during fever which resolved with treatment. The patient had an episode of syncope, which is likely to be reflex mediated. Brugada pattern can mimic acute anterior wall MI, which was effectively ruled out with normal cardiac enzymes and coronary angiogram.

Conclusions

The Brugada pattern closely mimics an anterior wall myocardial infarction and is an important differential diagnosis. Fever-induced Brugada is a recognized entity characterized by typical ECG patterns during fever. Recognizing ECG patterns and the clinical entity has important diagnostic and therapeutic implications.

References

  1. Porres JM, et al. Fever unmasking the Brugada syndrome. Pacing Clin Electrophysiol. 2002;25:1646-8.
  2. Adler A, et al. Fever-induced Brugada pattern: how common is it and what does it mean? Heart Rhythm. 2013;10(9):1375-82.
  3. Dumaine R, et al. Ionic mechanisms responsible for the electrocardiographic phenotype of the Brugada syndrome are temperature dependent. Circ Res. 1999;85:803-9.
Dr.-P.-Vijay Shekhar

Dr. P. Vijay Shekhar

Consultant Cardiologist

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