Brugada Syndrome Manifesting Only During Fever in Patient with Septic Shock Secondary to Post-Obstructive Pneumonia

Abstract

Patient: Male, 63Final Diagnosis: Multi organ failure/septic shockSymptoms: Abdominal pain • bloatingMedication: —Clinical Procedure: —Specialty: CardiologyObjective:Rare diseaseBackground:Brugada syndrome is a cardiac disorder associated with sudden death due to sodium channelopathy, most commonly the SCN5a mutation. There are 3 different patterns of electrocardiogram (ECG) changes characterized as type I, II, and III. ECG patterns consist of variations of incomplete RBBB and ST elevation in anterior pre-cordial leads only. Treatment, if warranted, consists of implantable cardioverter-defibrillator.Case Report:A 63-year-old male presented with abdominal pain for 4 days that was persistent, and after further imaging, he was found to have hepatic metastases from a stage IV small cell carcinoma of the lung. The patient was started on chemotherapy with carboplatin and VP-16. The patient decompensated, developed septic shock secondary to post-obstructive pneumonia, and eventually required intubation. He became tachycardic, and an ECG was ordered to evaluate the heart rhythm. It was determined that the patient had Brugada wave/syndrome. The patient’s condition deteriorated with worsening septic shock, suspected type II NSTEMI, and multiorgan failure. The patient was designated DNR (“do not resuscitate”) and passed away.Conclusions:This case represents how channelopathies can be provoked with fever. It is believed that this occurs due to denaturing of the ion channel leading to abnormal ST segment changes typically seen on ECG and an increased risk of developing lethal arrhythmias. Spontaneous presentation of nondrug-induced Brugada syndrome carries an increased risk of deadly arrhythmia, for which this patient would have required electrophysiological studies. Unfortunately, this patient was unable to undergo genetic testing or electrophysiological studies, as he passed away.

Brugada Pattern Manifesting During Hyperkalemia, Diabetic Ketoacidosis, and Acute Alcohol Intoxication

“…This may also explain how Brugada patterns can be revealed by moving V1 and V2 more superior or cranially on the precordium to the second intercostal space. The sodium channel derangements lead to early after depolarizations from the right ventricular outflow tract epicardium, ultimately leading to oscillations of potential QRS depolarizations, which can exceed the threshold, which triggers a true ventricular event such as ventricular fibrillation or tachycardia [ 13 ]. This slows the upstroke of the phase 0 cardiac action potential, and the L-type inward calcium channels and transient dependent outward current during phase 1 have also been implicated as a substrate for Brugada morphology and arrhythmias [ 14 ].…”

Fever and Hyponatremia Unmasking Brugada Pattern Electrocardiogram in a Patient With SARS-CoV-2 Infection

“…Brugada pattern has been noted to occur in systemic infections [ 11 ], including viral infections such as influenza [ 12 ], likely as a result of fever. COVID-19 is a newly recognized infectious disease that has caused a worldwide pandemic, presenting mainly with fever, pneumonia, and hypoxic respiratory failure.…”

Brugada syndrome

“…A 29-year old male who met 7 out of 8 diagnostic criteria for hemophagocytic syndrome induced by Chlamydophila pneumoniae was also found to display a Brugada ECG pattern when he had a fever, with normalisation of the ECG pattern upon Chlamydophila pneumoniae infection and hemophagocytic syndrome treatment [105]. Fever-induced BrS was also reported in a 63 year old male patient who specifically had post-obstructive pneumonia and concomitant small cell lung cancer [106]. As mentioned above however, fever can also trigger arrhythmic events in addition to inducing a type-1 ECG pattern and this remains the main risk in these patients.…”