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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 219-221

Reversible Brugada like electrocardiographic pattern in COVID-19 infection


1 Department of Cardiology, Government Stanley Medical College, Chennai, Tamil Nadu, India
2 Department of Pediatrics, Division of Pediatric Hemato-Oncology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission17-Oct-2021
Date of Acceptance05-Nov-2021
Date of Web Publication6-Dec-2021

Correspondence Address:
Kamal Kant Jena
Department of Cardiology, Government Stanley Medical College, Chennai - 600 001, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_148_21

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  Abstract 


Brugada syndrome, a rare genetic disease increases the risk of arrhythmias and sudden cardiac death. Various trigger factors has been associated with Brugada syndrome. Arrhythmias have been reported in COVID 19. We report a patient with transient Brugada like pattern in ECG triggered by COVID 19.

Keywords: Brugada syndrome, COVID 19 pneumonia, trigger factor


How to cite this article:
Jena KK, Singh PK, Elamaran C, Ramachandran P, Kannan K, Arul J. Reversible Brugada like electrocardiographic pattern in COVID-19 infection. Saudi J Health Sci 2021;10:219-21

How to cite this URL:
Jena KK, Singh PK, Elamaran C, Ramachandran P, Kannan K, Arul J. Reversible Brugada like electrocardiographic pattern in COVID-19 infection. Saudi J Health Sci [serial online] 2021 [cited 2022 Jan 22];10:219-21. Available from: https://www.saudijhealthsci.org/text.asp?2021/10/3/219/331772




  Introduction Top


Brugada syndrome (BS), a familial genetic disease, caused by mutation in SCN5A gene leads to ventricular arrhythmias and sudden cardiac death was initially reported in 1992.[1] Various trigger factors such as fever, antidepressant drugs, anti-arrhythmic drugs, cocaine, hormonal imbalance, electrolyte abnormalities, and exercise have been well-described to induce BS.[2] Although coronavirus disease 2019 (COVID-19) majorly presents with severe pulmonary complications, recently cardiovascular complications such as myocardial injury, acute myocardial infarction and ischemia, and various thrombo-embolic phenomenon also have been described.[3] Arrhythmias also have been recently described in COVID-19.[4] We describe a case of BS which was unmasked by COVID-19 pneumonia.


  Case Report Top


A 16-year-old male presented with a history of fever, myalgia, throat pain, and cough with no sputum for 3 days. There was no history of breathlessness or palpitation. There was no relevant past, personal, or treatment history. On examination, he was afebrile at the time of presentation, jugular venous pressure was normal, respiratory rate was 22/min, blood pressure was 130/80 mm of hg, pulse rate was 114/min, and SpO2 was 98% in room air. Respiratory system examination revealed coarse occasional crackles in the inter-scapular region. All other systemic examinations were found to be normal.

Routine blood investigations revealed normal complete blood count, serum sodium, potassium, calcium, and magnesium were found to be normal. Erythrocyte sedimentation rate and high-sensitive C-reactive protein were found to be elevated. Troponin I was elevated. NT-proBNP level was <300 pg/dl. COVID-19 test done by the reverse transcription polymerase chain reaction was positive. All other blood investigations were unremarkable. Computed tomography of the thorax revealed mild ground-glass opacity in the bilateral middle zones with peripheral predominance [Figure 1].
Figure 1: Computed tomography of the thorax showing bilateral ground-glass opacity with peripheral predominance suggestive of COVID-19 pneumonia

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The electrocardiogram (ECG) showed heart rate of 114/min, sinus tachycardia, normal axis, normal P-wave morphology, QRS was duration was normal, ST-segment showed elevation in V1 and V2 leads with coved appearance suggestive of Type 1 Brugada-like pattern [Figure 2], with T inversion in V3, V4, and V5 with no reciprocal changes. Echocardiogram revealed no regional wall motion abnormality and normal left ventricular systolic function, with ejection fraction of 68%.
Figure 2: 12 lead electrocardiogram -heart rate-114/min, normal sinus rhythm, normal axis, normal P-wave morphology, QRS duration of 70 ms, ST segment shows coved elevation of 3 mm in V1 and 5 mm in V2 suggestive of type 1 Brugada pattern, with no reciprocal changes

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He was treated for COVID-19 pneumonia as per the protocol. Heparin and anti-platelets were started with a probable diagnosis of non-ST-elevation myocardial infarction. He became asymptomatic in 6 days and repeat ECG [Figure 3] was taken on the 5th day showed complete resolution of the ST elevation (Brugada-like pattern) and disappearance of T-wave inversions in the anterior leads. Coronary angiogram revealed normal coronaries [Figure 4]. He was discharged after 10 days of isolation.
Figure 3: Repeat electrocardiogram at 5th day heart rate − 71/min, normal sinus rhythm, normal axis, normal P-wave morphology, QRS duration of 50 ms, normal ST segment, with complete resolution of Brugada pattern

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Figure 4: Coronary angiogram: (a) RAO caudal view showing normal left anterior descending artery and left circumflex arteries. (b) Showing normal right coronary artery

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  Discussion Top


ST segment and rhythm abnormalities have been described in association with COVID-19 infection.[4],[5] Recently, few case reports have emerged suggesting BS and Brugada like ECG pattern in association with COVID-19 infection.[6],[7] BS is a genetic disorder, most commonly involving loss-of-function mutation of SCN5A gene with an overall prevalence of 1 in 5,000–1 in 20,000.[8] BS usually presents with palpitations, syncope, aborted sudden cardiac arrest and ventricular arrhythmia, which is found be higher in Type 1 BS.[8] BS is classified into two types. Type 1 or the coved type and the Type 2 or the saddle back type.[8] Our patient had Type 1 BS.

Although lots of aggravating factors have been mentioned earlier, fever has been found to be an importing inciting factor for developing arrhythmias or revealing spontaneous Type 1 BS.[8] Our patient also did not have fever at the time of presentation. People with Type 2 BS require an anti-arrhythmic provocative test to develop Type 1 BS to confirm.[9]

Recent studies reveal that COVID-19-induced cytokine storm is found to cause myocarditis and pericarditis leading to left ventricular dysfunction. Mechanisms of arrhythmias in COVID-19 have also been reported to be the same.[10] Hence, we also suspect that our patient might have also had myocardial injury leading to transient Brugada-like ECG pattern.

Intra cardiac defibrillator (ICD) is indicated in patients with family history of sudden cardiac death, past history of ventricular arrhythmias or who recovered from a sudden cardiac arrest.[9] Our patient has no past or family history of the same; hence, ICD was not indicated, hence he was only advised for further monitoring and routine follow-up and counselled regarding future such episodes and arrhythmias. Although in the recent times epicardial ablation has been tried in selected patients of BS, longer follow-up period is require to find out a definitive conclusion.[8]

COVID-19 disease symptomatically ranges from mild fever, myalgia to severe respiratory distress requiring invasive ventilation. Cardiac correlations have also been described in the recent past. We hereby in our case report show a case of COVID-19 illness inducing an asymptomatic Type 1 BS.


  Conclusion Top


COVID-19 usually presents with fever which is an inciting factor of BS in the majority of asymptomatic patients who are at risk of arrhythmias and sudden cardiac arrest. Hence, COVID-19 patients with known BS need close monitoring and more aggressive anti-pyretic therapy and follow-up with serial ECGs. These patients with arrhythmias may require ICD in follow-up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Brugada P, Brugada J. Right bundle branch block, persistent ST segment elevation and sudden cardiac death: A distinct clinical and electrocardiographic syndrome. A multicenter report. J Am Coll Cardiol 1992;20:1391-6.  Back to cited text no. 1
    
2.
Sarquella-Brugada G, Campuzano O, Arbelo E, Brugada J, Brugada R. Brugada syndrome: Clinical and genetic findings. Genet Med 2016;18:3-12.  Back to cited text no. 2
    
3.
Long B, Brady WJ, Koyfman A, Gottlieb M. Cardiovascular complications in COVID-19. Am J Emerg Med 2020;38:1504-7.  Back to cited text no. 3
    
4.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 4
    
5.
Kochav SM, Coromilas E, Nalbandian A, Ranard LS, Gupta A, Chung MK, et al. Cardiac arrhythmias in COVID-19 infection. Circ Arrhythm Electrophysiol 2020;13:e008719.  Back to cited text no. 5
    
6.
Chang D, Saleh M, Garcia-Bengo Y, Choi E, Epstein L, Willner J. COVID-19 infection unmasking brugada syndrome. HeartRhythm Case Rep 2020;6:237-40.  Back to cited text no. 6
    
7.
van de Poll SW, van der Werf C. Two patients with COVID-19 and a fever-induced brugada-like electrocardiographic pattern. Neth Heart J 2020;28:431-6.  Back to cited text no. 7
    
8.
Brugada J, Campuzano O, Arbelo E, Sarquella-Brugada G, Brugada R. Present status of brugada syndrome. J Am Coll Cardiol 2018;72:1046-59.  Back to cited text no. 8
    
9.
Andorin A, Behr ER, Denjoy I, Crotti L, Dagradi F, Jesel L, et al. Impact of clinical and genetic findings on the management of young patients with brugada syndrome. Heart Rhythm 2016;13:1274-82.  Back to cited text no. 9
    
10.
Boukhris M, Hillani A, Moroni F, Annabi MS, Addad F, Ribeiro MH, et al. Cardiovascular implications of the COVID-19 pandemic a global perspective. Can J Cardiol 2020;36:1068-80.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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