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A 59 year–old male without relevant past medical history presented to our hospital because of an episode of chest pain followed by a syncope during driving, completely resolved once arrived at the ED. He complained of other chest pain episodes in the last past weeks. During hospitalization he has been asympthomatic and physical examination was unremarkable. ECG showed q waves in inferior leads and a Brugada pattern type 2. Cardiac enzymes were normal. Echocardiography showed akinesis of medio–basal inferior wall with slight reduction of EF (50%). Coronary angiography demonstrated a total occlusion of RCA and a 50% stenosis of LCA, treated with PCI and DES implantation. A following ECG revealed a spontaneous Brugada pattern type 1. This element let us reevaluate his past syncope nature. Electrophysiologists were consulted and the patient was deemed to be at low risk for sudden cardiac death. No ICD was indicated and a loop recorder was implanted. He underwent genetic test for Brugada syndrome, still pending at the moment. Brugada syndrome is a congenital electrical disorder associated with a high risk of ventricular arrhythmias and sudden cardiac death. Cardiac sodium channel gene SCN5A mutations represent the most frequent genetic variant, also associated with other cardiac disorders, but other potentially pathogenic variants have been reported. Brugada syndrome is diagnosed in patients with a spontaneous type 1 ECG pattern, characterized by J point elevation of > 2 mV with coved ST elevation and T wave inversion in at least one right precordial ECG lead, V1 or V2, positioned in the second, third or fourth intercostal spaces. This is an unusual case of incidental evidence of Brugada pattern type 1 after coronary revascularization. According to latest guidelines, our patient, due to his unexplained syncope nature, was deemed to loop recorder implantation (IIA Class). Actually his syncope could be due to the total occlusion of RCA or an arrythmia correlated to Brugada syndrome. Only loop recorder monitoring and genetic test results will help us in our patient’s management and to consider the possibility of ICD implantation.

A 25–year–old woman was admitted to our department with a diagnosis of pericarditis and pericardial effusion. She reported a flu episode 5 months earlier followed by persistent dry cough, dyspnoea on exertion and palpitations. Due to the persistence of symptoms, she consulted a cardiologist and it was observed a mild to moderate pericardial effusion with a raised C reactive protein at lab test. At first she was treated with ibuprofen and colchicine. After 2 months, prednisone was added to the therapy for effusion worsening. During steroids descalation she started complaining of night fever. Few weeks later an echocardiogram revealed increased pericardial effusion (21 mm) with signs of right atrial compression, so she was admitted to our department. No cardiovascular risk factors were reported but overweight and smoking habit. ECG at admission showed a slight depression of PR in inferior leads. Given the history, persistence of elevated inflammatory markers and fever on admission, despite prolonged therapy with NSAIDs, the patient was treated for high–risk pericarditis, with ibuprofen and colchicine. In addition, aetiological research was pursued: autoantibody and viral panel were negative; chest X–ray showed mediastinal enlargement and swelling in the right hilar region. So an urgent chest CT scan was performed and it showed a 8x9 cm mediastinal mass extending to the pectoral muscles and sternum. The mass biopsy revealed a classical Hodgkin lymphoma so she was transferred to Hematology department and chemotherapy was started. During her hospital stay, the effusion remained stable (17 mm). This clinical case demonstrates that pericarditis, even in a young patient, with a lack of response to NSAIDs therapy and with an unremitting course, must raise the suspicion of an occult cancer. In fact, according to the latest guidelines, in case of high–risk pericarditis, i.e. in the presence of at least one negative prognostic predictor between fever higher than 38°C, subacute onset, severe pericardial effusion, tamponade or failure of medical therapy after one week, aetiological research is indicated, in addition to hospitalization. It shouldn‘t be forgotten that pericarditis may be the first manifestation of an occult extracardiac tumor. In particular, the primary tumors associated with pericarditis are breast cancer, lung cancer and lymphomas. Probably better case management would have allowed an earlier diagnosis and treatment of our patient‘s cancer.