Brugada Phenocopy Amidst A Metabolic Catastrophe!

The above electrocardiograms (ECG) were obtained in the setting of multiple electrolyte and metabolic derangements. There was profound hyponatremia, hyperkalemia, hypermagnesemia, hypocalcemia, hyperphosphatemia and severe lactate elevation, in addition to significant hypothermia, anemia and demonstrated inferior vena cava (IVC) thrombus on CT imaging. Fig. A, initial ECG, demonstrates mild ST coving in V1 suggestive of Brugada (red arrow) in addition to peaked T waves indicative of hyperkalemia (blue arrow) and small Osborne waves in the lateral leads (green arrow) indicative of hypothermia. After initial treatment, in the first few hours (Fig. B), with improvement of the fever and optimization of the electrolytes, the Osborne waves became much smaller (green arrow) and the peaked T waves became less prominent (blue arrow). There was, however, more noticeable Brugada pattern as shown in Fig. B red arrow. Following normalization of the electrolytes and metabolic abnormalities, repeat ECG (Fig. C) the next day revealed resolution of the Brugada changes (red arrow), peaking of T waves (blue arrow) and Osborne waves (green arrow).