Brugada-like pattern and myocarditis in a child with multisy
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A 5-year-old Caucasian boy was admitted to the hospital because of fever, tachypnoea, chest discomfort, hypotension, and skin rash. Twelve-lead electrocardiogram (ECG) recorded at admission. Transthoracic echocardiogram revealed normal left ventricular diameters, septal hypokinesia, systolic dysfunction (ejection fraction 45%), and mild pericardial effusion.

Blood test revealed moderate elevation of high sensitive Troponin (highest value 434?ng/L), marked elevation of brain natriuretic peptide (721?ng/L), and inflammatory marker (C-reactive protein 12?mg/dL). Serology for SARS-CoV-2 was positive (IgG), while molecular PCR assay on nasopharyngeal swab was negative. The troponin curve displayed multiple spikes with a long plateau phase.

The presented clinical scenario satisfies the diagnostic criteria of multisystem inflammatory syndrome in children (MIS-C). 12-lead ECG shows sinus tachycardia (130 b.p.m.) and marked ST-elevation in V1–V2, and right axis deviation. The differential diagnosis of these localized repolarization abnormalities includes Type 1 (coved-type) Brugada pattern triggered by fever, acute focal myocarditis, and regional transmural ischaemia secondary to Kawasaki-like coronaritis in the setting of MIS-C.

Fever is a known trigger able to unmask Brugada pattern, and the observed ST-elevation in V1–V2 is compatible with the classical type I Brugada (coved-type). However, clinical features, elevated markers of myocardial damage, and echocardiographic findings favour an acute structural process rather than pure electrical disease.

Electrocardiogram recorded the following days showed QRS fragmentation and voltage reduction in V1–V2, consistent with myocardial oedema and fibrosis.

The hypothesis of acute myocardial ischaemia was considered unlikely since chest pain features were indicative of pericardial irritation (e.g. increasing by cough and deep inspiration), and there were no echocardiographic signs of inflammatory coronary involvement. In addition, the troponin trend did not display a typical ischaemic pattern.

The patient was treated with intravenous immunoglobulin and steroids. Symptoms, including fever, remitted gradually in a few days, ventricular function, and ECG normalized in 1 week.