A Case of Brugada Syndrome… or Something Else? Behind Type 1 Brugada Pattern

Although Brugada syndrome has traditionally been considered a primary electrical disease, accumulating evidence supports the presence of subtle structural abnormalities, particularly involving the right ventricular outflow tract. Nevertheless, the identification of overt myocardial scar and biventricular arrhythmogenic substrate should prompt consideration of an alternative diagnosis. We report the case of a 51-year-old man presenting with syncope during a febrile illness and a transient spontaneous type-1 Brugada ECG pattern. Initial evaluation was unremarkable. However, Holter monitoring revealed multifocal ventricular ectopy, including non-sustained ventricular tachycardia (NSVT) with both left and right bundle branch block morphologies, suggesting biventricular origin. Cardiac magnetic resonance showed a non-ischemic subepicardial scar, and electroanatomical mapping identified additional right ventricular abnormalities. Programmed stimulation induced sustained ventricular arrhythmias. These findings supported the presence of an underlying biventricular structural scar cardiomyopathy presenting with a fever-induced type-1 Brugada ECG pattern. The patient underwent transvenous ICD implantation. This case highlights the importance of a comprehensive multimodal diagnostic approach.