Ventricular flutter triggered by fever in a patient with Brugada syndrome William F. McIntyre, BSc, MD, a, ⁎ Francisco Femenía, MD, b Mauricio Arce, MD, b Emilce Trucco, MD, b Jorge Palazzolo, MD, b Andrés Ricardo Pérez-Riera, MD, PhD, c Adrian Baranchuk, MD, FACC, FRCPC a a Queen's University, Kingston, Ontario, Canada b Hospital Español, Mendoza, Argentina c ABC Faculty of Medicine, Sao Paulo, Brazil Received 25 October 2011 Abstract Brugada syndrome is a clinical-electrocardiographic entity predisposing to malignant ventricular arrhythmias. The typical arrhythmia is polymorphic ventricular tachycardia, which can potentially degenerate to ventricular fibrillation. Monomorphic ventricular tachycardia is uncommon. Our group is reporting the case of a 39-year-old man with known Brugada syndrome who developed ventricular flutter while febrile. Fever has previously been shown to unmask Brugada changes and to induce ventricular arrhythmias. The appearance of monomorphic ventricular tachycardia potentially attri- butable to sodium-channel dysfunction further confounds the mechanism of arrhythmogenesis in Brugada syndrome. This curious occurrence further underlines the likely complex nature of arrhythmogenesis in Brugada syndrome. © 2012 Elsevier Inc. All rights reserved. Keywords: Brugada syndrome; Fever; Monomorphic ventricular tachycardia; Ventricular flutter Introduction Brugada syndrome (BrS) is a clinical-electrocardiographic entity predisposing to ventricular arrhythmia and sudden cardiac death. It is defined electrocardiographically by a characteristic pattern including J point and an ST-segment elevation of 2 mm or greater, followed by a negative T wave in the right precordial leads. It has been closely linked to SCN5A gene mutations affecting sodium-channel function. 1 The typical arrhythmia of BrS is polymorphic ventricular tachycardia (PVT), which can potentially degenerate to ventricular fibrillation. 1,2 Repetitive monomorphic ventricu- lar tachycardia (MVT) including ventricular flutter (VFl) occurring in the context of BrS is a potentially lethal event. Repetitive MVT triggered by fever has only been described previously in a single case. 3 Clinical case A 39-year-old man with BrS (syncope, spontaneous type-1 electrocardiogram [ECG] pattern, negative genetics; Fig. 1A) received a single-chamber implantable cardioverter- defibrillator (ICD) (St Jude Medical Inc, St Paul, MN) 2 years before the event reported herein. He had no therapies deli- vered by the implantable cardioverter-defibrillator up to the time of this case. The patient presented to hospital com- plaining of confusion, lightheadedness, fever, and irritative lower urinary tract symptoms. Physical examination revealed an irregular heart rate of 110 beats/min, a blood pressure of 90/60 mm Hg, and a core body temperature of 39.2°C. Laboratory investigations showed the following: hemo- globin, 150 g/L; leukocyte count, 10.5 × 10 9 cells/L; ery- throcyte sedimentation rate, 30 mm/h; sodium, 135 mmol/L; potassium, 3.5 mmol/L; magnesium, 1.2 mmol/L; glucose, 4.9 mmol/L; creatinine, 107 μmol/L; urea, 6.4 mmol/L; and cardiac enzymes, negative. Findings of serial blood and urine cultures were negative. The patient was resuscitated with intravenous crystalloids and administered ciprofloxacin (1000 mg/24 h) and metami- zole (1 g/24 h) intravenously. He was admitted to an intensive care unit with continuous cardiorespiratory monitoring. During the first few hours of his hospital stay, the patient experienced an episode of presyncope, and the ECG (Fig. 1B) showed a Brugada type-1 pattern evolving to MVT. The ventricular tachycardia (VT) had a short cycle length, sinusoidal pattern, absence of T waves and, an Available online at www.sciencedirect.com Journal of Electrocardiology 45 (2012) 199 – 202 www.jecgonline.com ⁎ Corresponding author. Department of Medicine, Queen's University, Etherington Hall, 94 Stuart St, Kingston, Ontario, Canada K7L 3N6. E-mail address: wfmcintyre@gmail.com 0022-0736/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jelectrocard.2011.12.009