A 35-year-old Asian male presented to the hospital with a syncopal episode while he was walking home from a restaurant. He had two glasses of wine that evening but had been feeling dizzy and lightheaded in recent weeks. He did not have any significant past medical history and was not on any regular medication. He denied any palpitations, chest pain, or shortness of breath. He could not recall the syncopal episode fully and was found at the roadside by bystanders. On arrival at the hospital, his electrocardiogram (ECG) showed normal sinus rhythm (NSR) with right axis deviation (RAD) and right bundle branch block (RBBB) (Figure 1).
He had sustained facial and hand injuries. Most blood tests including troponin T, creatinine kinase, HbA1c, immune screening tests such as complement levels, rheumatoid factor, proteinase 3 antibody, myeloperoxidase antibody, myocardial antibody, and cardiolipin antibody, thyroid function tests, creatinine kinase were within normal limits. Viral screening for human immunodeficiency virus, hepatitis, and COVID-19 was negative. The erythrocyte sedimentation rate was mildly elevated at 14 mm/hour (Normal range: 1-10 mm/hr). Computerized tomography (CT) scan of the head and face showed a small fracture to the superior maxillary wall with overlying soft tissue swelling without any intracranial pathology. CT pulmonary angiogram showed florid centrilobular nodular opacification affecting the right upper and middle lobes, hilar lymphadenopathy, and anterior abdominal lymphadenopathy suggestive of possible tuberculosis (Figure 2). Following further investigation and respiratory input, it was felt tuberculosis was highly unlikely. He was commenced on bisoprolol 2.5 mg once daily.
Echocardiography showed normal biventricular function with an estimated left ventricular ejection fraction (LVEF) of 55% and no regional wall motion abnormalities (Videos 1-2). Cardiovascular magnetic resonance imaging (CMR) showed normal biventricular function, mild atrial dilatation, and extensive, crescent-shaped, subepicardial late gadolinium enhancement seen in basal to apical inferior, basal to apical lateral, and mid to apical anterior segments (Figures 3-5).
The patient was offered an implantable cardioverter defibrillator (ICD) for secondary prevention. The patient was discussed in a multidisciplinary team meeting (MDT) for subcutaneous versus transvenous ICD and had subcutaneous ICD screening which was normal. A transvenous ICD was implanted following a multidisciplinary team meeting. Chest radiography post-ICD implantation showed satisfactory leads positioning (Figure 5). Post-implantation device checks were satisfactory, and the patient was discharged home on bisoprolol 2.5 mg once daily with outpatient cardiology follow-up in the device clinic.