# Fever, Syncope, and the Brugada Dilemma: Navigating the Complexities of ICD Decision-Making in an Atypical Presentation

## TL;DR

A young man with a Brugada syndrome-like EKG pattern and syncope received an ICD for sudden cardiac death prevention despite unclear risk factors.

## Contribution

This case highlights the diagnostic and management challenges in intermediate-risk Brugada syndrome patients with atypical presentations.

## Key findings

- A 20-year-old male with syncope and a Brugada Type 1 EKG pattern was managed with an ICD despite a negative procainamide challenge.
- Atypical right bundle branch block suggested sodium channel dysfunction in the absence of structural heart disease.
- The case illustrates complexities in ICD decision-making for intermediate-risk Brugada syndrome patients.

## Abstract

Brugada syndrome (BrS) is a rare inherited cardiac channelopathy associated with ventricular arrhythmias and sudden cardiac death (SCD), often in individuals with structurally normal hearts. It is diagnosed by a Type 1 electrocardiographic (EKG) pattern—coved ST-segment elevation in the right precordial leads. Fever is a known trigger that can unmask Brugada patterns by worsening sodium channel dysfunction. We present the case of a 20-year-old male with a fever and an episode of syncope prior to admission who had an EKG showing a Type 1 Brugada pattern. Procainamide challenge was negative, but an atypical right bundle branch block suggested sodium channel dysfunction. Despite the absence of structural heart disease, an implantable cardioverter defibrillator (ICD) was placed for primary prevention of SCD. This case underscores the diagnostic and management challenges in intermediate-risk BrS patients.