Brugada Pattern in a Child with Severe SARS-CoV-2 Related Multisystem Inflammatory Syndrome

Abstract

This report presents the first case of Brugada pattern complicated by a supraventricular arrhythmia in a child with SARS-CoV-2 related Multisystem Inflammatory Syndrome in Children (MIS-C). A 7-year-old boy came to our Emergency Department with 7 days of abdominal pain and fever. MIS-C was diagnosed on the basis of the clinical, laboratory and instrumental tests. On admission, ECG showed type 1 Brugada pattern in the right precordial leads. During hospitalization the onset of supraventricular arrhythmias complicated the clinical picture. This case underlines management complexity of supraventricular arrhythmic events, different from atrial fibrillation, in patients with Brugada pattern in the context of a systemic inflammatory condition with significant cardiac involvement. All potential therapeutic choices should be considered to ensure the best outcomes.

Keywords: Brugada syndrome; SARS-CoV-2; children; multisystem inflammatory syndrome.

Figure 1

First electrocardiogram recorded on admission showing Brugada type 1 pattern in V1 and V2. It is characterized by a coved ST-segment elevation displaying J-point amplitude or ST-segment elevation ≥2 mm, followed by a negative T wave in more than one right precordial leads (V1 to V3).

Figure 2

Pedigree showing the patient’s (IV 1) family history. A cousin of the patient’s father died of sudden cardiac death at the age of 35 (III 1).

Figure 3

Progressive improvement of inflammation and cardiac markers and ECG normalization during treatment with intravenous immunoglobulins and methylprednisolone boluses. Troponin on admission was 23 ng/L (normal reference value for age < 14) and normalized at the 2nd day of treatment.

Figure 4

Atrial ectopic tachycardia (AET) at heart rate of 120 beats/min recorded on day 2 of hospitalization. The diagnosis is based on the presence of a regular narrow QRS complex tachycardia with an abnormal P-wave morphology originating from an ectopic focus. As shown in the magnification insert, the P-wave is not visible because it is morphologically different from the sinus one and it is fused with the preceding T-wave.

Figure 5

Sinus rhythm with first-degree atrioventricular block (AVB) in progress of MIS-C associated with coronavirus disease 2019 (COVID-19). First-degree AVB is a delay, without interruption, in conduction from atria to ventricles resulting in an increased PR interval greater than 200 ms.

Figure 6

Complete ECG normalization after 7 days of MIS-C treatment according to current guidelines.