Fournier’s Gangrene-Associated ECG-Pickelhaube Sign

BACKGROUND: The spiked helmet sign (SHS), or Pickelhaube sign, is a rare pseudo-ST-segment elevation pattern described in critically ill patients without acute myocardial infarction. CASE SUMMARY: A 30-year-old man with class III obesity and diabetes presented in septic shock from extensive Fournier's gangrene. After emergent debridement, telemetry showed anterior ST-segment elevation prompting ST-segment elevation myocardial infarction (STEMI) activation. Serial electrocardiograms demonstrated pre-QRS baseline elevation merging with the QRS and transient anterolateral ST-segment elevation consistent with the Pickelhaube sign. Troponins remained normal, and contrast echocardiography showed hyperdynamic systolic function without regional wall-motion abnormalities. ST elevation resolved spontaneously within 30 minutes, and angiography was deferred. He required vasopressors, continuous venovenous hemofiltration, repeated debridement, and wound vacuum-assisted closure before discharge to long-term acute care. DISCUSSION: This case demonstrates the Pickelhaube sign during Fournier's gangrene with septic shock. Recognizing its morphology and evolution, along with biomarkers, echocardiography, and clinical context, can distinguish pseudo-STEMI from acute coronary occlusion and avoid unnecessary angiography. TAKE-HOME MESSAGES: The Pickelhaube sign can occur in severe necrotizing soft-tissue infection and septic shock and may closely mimic acute STEMI. Serial electrocardiograms, cardiac biomarkers, echocardiography, and hemodynamic context help distinguish this pseudo-STEMI pattern from acute coronary occlusion.