[SCD-FORUM] 63C An Unusual QRST Pattern in A Patient with Severe Hypokalemia. Dr. Wang

[SCD Symposium]

An Unusual QRST Pattern in A Patient with Severe Hypokalemia
A 31-year-old male was admitted with muscle weakness of the  
extremities, paralysis and
dyspnea. The patient felt tired for 12 hours with nasal discharge,  
nausea and one episode of
vomiting, but had no fever or cough. The patient had been sent to a  
local clinic where he
received IV hydration. His muscle weakness got worse and he developed  
paralysis 6 hours
before the admission.
In the past, the patient was in good general health. There was no  
history of allergy to
mediation or food. He denied history of hepatitis or tuberculosis.  
There was no history of
contact with industrial poison and radioactive substances. There was  
no history of surgery or
trauma.
Physical examination: T: 36.4°C,P: 66/min,R: 20/min,BP: 130/60 mmHg.  
The patient
was in no acute distress. There was exophthalmos bilaterally. The  
thyroid was enlarged and
felt to be somewhat solid, with normal mobility but no flow murmur.  
Lungs were clear. Heart
showed some irregularity, but no murmur. Physical reflexes were  
within the normal range,
but the extremity muscle strength was zero degree. Muscular tension  
decreased in the arms,
but increased in the legs.
Stat electrocardiogram (EKG) showed Sinus arrhythmia with a rate of  
61/min. The P-R,
QRS and Q-T intervals measured 260, 120 and 360 ms, respectively. QU  
interval=670 ms.
There was an rSr’ pattern of the QRS complex in leads V1 through V3,  
with r < r’. There was
ST segment downsloping elevation of 0.2 mV with inverted T wave in  
leads V1 and V2. T
wave was flat in lead V3. There was an Rs pattern with a tall R wave  
(3.8 mV) and a late
broad S wave in lead V5. There were prominent U waves in all the  
leads,more so in the
precordial leads.

http://www.scd-symposium.org/files/wang1.pdf


EKG diagnose:1) Sinus arrhythmia; 2) Io atrioventricular block; 3) High
voltage of the left ventricle; 4) Prominent U wave and QU  
prolongation suggesting
hypokalemia. 5) Atypucal Brugada ECG pattern.

Stat blood test revealed K+ was only 1.46 mmol/l,which was improved  
to 4.46mmol/l
with potassium supplement over 24 hours. A follow up EKG  
showed:Normal sinus rhythm
with a rate of 83/min. The P-R, QRS and Q-T intervals measured 160ms,  
80 and 380 ms,
respectively. There remained an rSr’ pattern of the QRS complex in  
leads V1 and V2,but r>
r’. The latter mimic a J wave, with a much lower amplitude when  
compared to the prior
electrocardiogram. There remained ST segment downsloping elevation in  
leads V1 and V2
(0.1—0.2mv) and T wave inversion in lead V1. But there was no longer  
T wave inversion in
leads V2 or V3. An upright R wave was appreciated in V3 as well as in  
leads V4 and V5. There
was a qRs pattern in lead V5, with a prominent J wave. The R wave  
remained to be tall in V5
(3.9mV). The u wave was no longer present in any leads.

http://www.scd-symposium.org/files/wang2.pdf

EKG diagnosis:1) Normal sinus
rhythm.  2) High voltage of the left ventricle; 3) Atypical Brugada  
EKG pattern.
The patient was subsequetly found to have elevated T3 and T4,  
therefore the final clinical
diagnosis was “thyrotoxicosis with periodic paralysis”.
Questions to the ECG expert Dr. Perez Riera:
   1) Do you consider whether this patient has a Brugada pattern or not?
      2) Want is your interpretation of the ECG, especially  
considering the unusual QRST
pattern in the right precordial leads?
Thank you,
Hongyu Wang, MD
Jiangping Li, MD
Second Hospital of Shanxi Medical University
PR. China




--
Dr. Sergio Dubner
President of Scientific Committee

Dr. Edgardo Schapachnik
President of Steering Committee




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