Pedro Dammert, MD
Bayhealth Hospital Kent Campus
Dover, Delaware
Disclosure information not submitted.
Sarah Robinson, DNP, FNP-BC
Nurse Practitioner
Eranga Cardiology, United States
Disclosure information not submitted.
Eranga Haththotuwa, MD
Cardiologist
Eranga Cardiology, United States
Disclosure information not submitted.
Title: Challenging Diagnosis of Brugada Syndrome in a Puerperal Woman Presenting with Loss of Consciousness
Case Report Body:
Introduction: Brugada syndrome is a genetic disorder associated with ventricular arrhythmias that can have a devastating prognosis. It can be difficult to identify due to variability in its presentation and dynamic ECG findings. We present a case of Brugada syndrome with a challenging diagnosis.
Description: A 30-year-old, 12 weeks post-partum woman was admitted after a witnessed episode of loss of consciousness. She was playing with her baby and suddenly became unresponsive. Per EMS account she had a pulse, had irregular respirations, was intubated enroute to the hospital and had seizure-like activity. On admission she was sedated and hemodynamically stable. Her ECG showed sinus rhythm with incomplete right bundle branch block, a chest CTA was negative for pulmonary embolism and a brain MRI was within normal limits. She was treated with antiepileptic drugs for possible seizures. The next day she was awake and alert off sedation and was extubated. A repeat ECG showed ST elevations in V1-V2 in the classic type 1 Brugada pattern. On further questioning, it was noted that a policeman who was the first responder, found the patient unconscious with no pulse, and started CPR before the arrival of EMS. Patient later gave a history of five previous syncopal episodes without prodrome, but no family history of sudden death. An echocardiogram showed normal systolic function, and an electrophysiology study showed no inducible arrhythmias but showed mild ST elevations in V1-V2 after procainamide provocation. A subcutaneous AICD was implanted and was discharged home. Since then, the patient has had no further episodes of syncope or arrhythmias.
Discussion: This case illustrates the difficulties in the diagnosis of Brugada syndrome. Firstly, important information was not evident initially, including the absence of pulse noted by the first responder on arrival, and the previous episodes of syncope, obtained from the patient after regaining consciousness. Secondly, the initial ECG did not show a Brugada pattern. This is not uncommon as often the characteristic ECG changes of the Brugada pattern are transient or variable over time. Repeated questioning to ensure a detailed history and serial ECGs were instrumental in arriving at the correct diagnosis and are recommended for all young patients with unexplained syncope or SCD.