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ST segment elevations in a patient with neutropenic fever

Published:December 18, 2016DOI:https://doi.org/10.1016/j.ejim.2016.12.004

      Highlights

      • ST segment elevations on EKG can be seen in other conditions such as BrS physiology
      • Drugs and fever can precipitate Brs
      • Diagnosis of BrS is crucial to prevent sudden cardiac death and fatal ventricular arrythmias
      • Placement of ICD in appropriate BrS patients
      • Screening of first degree relatives of BrS patients to identify asymptomatic BrS in family members
      A 31-year-old Caucasian man presented to the emergency department with sudden onset fever, chills and chest, pain two weeks after completing induction chemotherapy for acute myelogenous leukemia. Vitals were notable for tachycardia (heart rate 112/min), tachypnea (respiratory rate 26/min) and a temperature of 39.2 °C (102.6 °F). Laboratory analysis revealed leukopenia with an absolute neutrophil count of 320/μL. An electrocardiogram was performed (Fig. 1) which demonstrates >2 mm ST segment elevation in leads V1–V3 accompanied by downward sloping of the ST segment in leads V1–V3 (coved ST segment, especially in V1) and inverted T-waves in the corresponding leads. Subsequent cardiac enzymes including troponin T and creatinine kinase were negative. He reported ‘passing out’ several times since childhood, but had no personal history of palpitations, arrhythmias or sudden death in the family.
      Fig. 1
      Fig. 1Electrocardiogram of the patient demonstrating >2 mm ST segement elevation in leads V1-V3 accompanied by downward sloping of the ST segment in leads V1-V3(coved ST segment, especially in V1) and inverted T-waves in the corresponding leads.

      1. What is the diagnosis?

      1.1 Discussion

      The patient has Brugada Syndrome (BrS). Brugada Syndrome (BrS) is an inherited arrhythmia syndrome primarily due to mutations in the cardiac voltage-gated sodium channel (Scn5a) or the L-type voltage-gated sodium channel. EKG findings of BrS are right-bundle block like morphology along with ST elevation >2 mm, prolonged PR interval and negative T-wave. BrS is mainly a clinical diagnosis where combination of characteristic EKG findings with any one of the conditions like polymorphic ventricular tachycardia, ventricular fibrillation (VF), syncope or early sudden cardiac death in the family (<45 years old) is sufficient to diagnose the disease entity [
      • Mizusawa Y.
      • Wilde A.A.M.
      Brugada syndrome.
      ]. Psychotropic drugs and fever have been considered to be major precipitating factors behind unmasking the EKG patterns of BrS. as Risk factors for developing sudden cardiac deaths in BrS patients are syncope, a family history of sudden cardiac death and a positive electrophysiology study although isolated family history of BrS is not an independent risk factor for fatal ventricular arrhythmia in BrS patients [
      • Morita H.
      • Kusano-Fukushima K.
      • Nagase S.
      • Fujimoto Y.
      • Hisamatsu K.
      • Fujio H.
      • et al.
      Atrial fibrillation and atrial vulnerability in patients with Brugada syndrome.
      ,
      • Okamura H.
      • Kamakura T.
      • Morita H.
      • Tokioka K.
      • Nakajima I.
      • Wada M.
      • et al.
      Risk stratification in patients with Brugada syndrome without previous cardiac arrest – prognostic value of combined risk factors.
      ]. Management of BrS involves the use of an ICD in patients who have either survived sudden cardiac death or a documented spontaneous sustained ventricular tachycardia or in such patients who have spontaneous type I Brugada EKG pattern along with a history of syncope likely caused by a ventricular arrhythmia. Screening for BrS in first degree relatives is also recommended to diagnose asymptomatic BrS in family members.

      Author contributions

      AD drafted and revised the manuscript.AG provided care for the patient and conceptualized the report.AG and SD revised and edited the manuscript for intellectual content.

      Funding

      None.

      Informed consent

      Obtained.

      Conflict of interest disclosures

      None.

      Ethics committee approval

      Not applicable.

      References

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        Risk stratification in patients with Brugada syndrome without previous cardiac arrest – prognostic value of combined risk factors.
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