UNVEILING THE VILLAIN: AN INTRIGUING CASE OF DIAGNOSING BRUGADA SYNDROME

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Brugada syndrome is a rare condition that is associated with an increased risk of ventricular tachyarrhythmias and sudden cardiac death. The typical electrocardiographic features of Brugada syndrome are variable and are known to be revealed by several precipitants such as drugs, and febrile illnesses. The following case describes the incidental ECG findings of Brugada pattern in a patient who presented with dizziness, shortness of breath and recently diagnosed deep vein thrombosis in her left leg. CASE PRESENTATION: A 63-year-old female with a history of breast cancer on tamoxifen, and recently diagnosed deep vein thrombosis on rivaroxaban presented to the emergency department with shortness of breath. Chest x-ray revealed no radiographic abnormality. EKG was significant for coving ST segment elevations on V1 and V2 consistent with Brugada type 1. She underwent emergent left heart catheterization which revealed normal coronaries. CT chest with contrast demonstrated the presence of a right subsegmental pulmonary embolism. Echocardiography revealed a left ventricular EF of 70% and no valvular pathology. Her shortness of breath improved. She was counselled on risks, given a list of medications to avoid and advised to treat fevers. She declined to have genetic testing. DISCUSSION: The typical EKG features of Brugada syndrome are variable and are known to be revealed by several precipitants. The patient was not aware of any family history of Brugada syndrome. She stated that during her knee replacement surgeries, she had a witnessed vasovagal syncopal episode with no VF or VT reported on telemetry. CONCLUSIONS: This case highlights the presentation of Brugada syndrome in a patient precipitated by pulmonary embolism. It is recommended that such patients undergo genetic testing. Current recommendations are to place an ICD in those who survived cardiac arrest. Pharmacological treatment with quinidine is also an option. Treatment of asymptomatic patients is more complicated, and personalized risk-stratification is essential to providing the right management for these patients. REFERENCE #1: Antzelevitch C, Brugada P, Borggrefe M, et al. Brugada syndrome: report of the second consensus conference: endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation 2005;111:659–70 REFERENCE #2: Veltmann C, Schimpf R, Echternach C, et al. A prospective study on spontaneous fluctuations between diagnostic and non-diagnostic ECGs in Brugada syndrome: implications for correct phenotyping and risk stratification. Eur Heart J 2006;272544–52 REFERENCE #3: Lamelas P, Labadet C, Spernanzoni F, et al. Brugada electrocardiographic pattern induced by fever. World J Cardiol 2012;4:84–6 DISCLOSURES: No relevant relationships by HANAD BASHIR, source=Web Response No relevant relationships by Jeff Courson, source=Web Response No relevant relationships by NICOLE LAO, source=Web Response No relevant relationships by Gauranga Mahalwar, source=Web Response