FEVER-INDUCED BRUGADA SYNDROME

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Brugada syndrome (BrS) is a rare cause of sudden cardiac death in asymptomatic healthy adults. We present a case of BrS unmasked by fever secondary to COVID-19 infection. CASE PRESENTATION: 38-year-old male with no prior medical history presented with a two-day history of subjective fevers, chills, productive cough, dyspnea, and left-sided pleuritic chest pain. He was noted to be febrile, tachypneic, tachycardic and hypoxic to the low-90s on room air. Bloodwork revealed elevated inflammatory markers with leukocytosis. Imaging and bloodwork were consistent with severe bilateral multifocal pneumonia secondary to COVID-19 infection. EKG on admission showed evidence of sinus tachycardia and type I Brugada pattern in leads V1 and V2 without ischemic changes. He was admitted for treatment of COVID-19 pneumonia with intravenous (IV) Remdesivir, IV steroids, and oxygen supplementation. Despite this, patient continued to be febrile, and interestingly, serial EKGs showed persistent type 1 Brugada pattern, which transformed into type 2 Brugada pattern after day 2 of admission, to persist for the next seven days. Echocardiogram showed normal left ventricular systolic function (ejection fraction 65%) with no significant valvular abnormalities. The Brugada pattern was thought to be induced by the febrile episodes, therefore all fevers were aggressively treated, and patient was closely monitored for any ventricular arrhythmias. Patient was educated on avoiding tricyclic antidepressants and sodium channel blockers as they are contraindicated in BrS. He was discharged home with plans for outpatient electrophysiological study. DISCUSSION: BrS is a clinical entity that can lead to sudden cardiac death and is associated with ECG changes of a 2mm J-point elevation and 1mm ST-segment elevation in two or more of the right precordial leads;type 1 is characterized by coveted-ST elevation in V1 and V2 whereas type 2 involves a saddle-back appearance. Diagnosis is made after excluding all other known causes of ST-segment elevation in right precordial leads, known as phenocopies. Known triggers include fever, intoxication, vagal stimulation, electrolyte imbalances, and various medications. Fever-induced BrS is more common among men in an age group of 30 to 60 years [4], it can precipitate cardiac arrest due to increased arrhythmogenicity of cardiac sodium channels at higher temperatures. Thus, timely and aggressive control of fever is crucial in preventing fatal arrhythmias, with fever-induced BrS leading to cardiac arrest in 18-20% of patients [2,3]. CONCLUSIONS: Clinicians need to be aware of the circumstances that can induce BrS, including fevers and medications, as BrS can be fatal, leading to cardiac arrest in many patients. Early recognition can lead to early intervention, through placement of an implantable pacemaker for documented arrhythmia, to decrease morbidity and mortality. REFERENCE #1: 1. Bayes de Luna A, Brugada J, Baranchuk A, et al. Current electrocardiographic criteria for diagnosis of Brugada pattern: a consensus report. J Electrocardiol. 2012;45:433-442. [PubMed] [Google Scholar] REFERENCE #2: 2. Amin AS, Meregalli PG, Bardai A, Wilde AA, Tan HL. Fever increases the risk for cardiac arrest in the Brugada syndrome. Ann Intern Med. 2008;149:216-218. [PubMed] [Google Scholar] DISCLOSURES: No relevant relationships by Muhammad Hanif, source=Web Response No relevant relationships by Sudheer Konduru, source=Web Response No relevant relationships by Marino Leonardi, source=Web Response No relevant relationships by SANA MULLA, source=Web Response No relevant relationships by Ruqqiya Mustaqeem, source=Web Response No relevant relationships by Vihitha Thota, source=Web Response