Pseudo ECG myocardial infarction in young man with severe chronic chagasic cardiomyopathy

Young man (29yo), mulatto agriculture worker, coming from rural Chagasic-endemic area of Minas Gerais State, Brazil (San Francisco River). The patient himself informs clearly that his rural house was infested by triatomine bugs “bichos-barbeiros” or “chupança” at that time and that many times he was bitten by them during the night. Concerning weight gain the last Month ( 6Kg)

Physical
Head: Normocephalic. Eyes edematous, ears, and throat normal.
Neck: veins distended, increased jugular venous pressure to 12cm. Positive hepatojugular reflux. Carotids without bruits.
Chest: Scattered rhonchi throughout, rales bilateral one third lower bases.
Heart: The apex beat is about 6cm in diameter, or a little more than 2.5 fingertips. It is located in the seventh intercostal space in the anterior axilary line. A palpable pulmonary component of the second heart sound (P2).
Tachycardial pulses (106bpm), and regular. Wide splitting of the second heart sound with an accentuated second component (P2), Third S3 diastolic gallop and fourth heart sounds was noted. Mitral systolic murmur Grade 3/6 irradiate to axila and left sternum border.
Abdomen: Distended abdomen. Liver sensitive and palpable fourth centimeters below right costal margin (hepatomegaly).
Genitalia: swelling scrotum.
Extremities: Swelling of feet and ankles, no clubbing. Pulses intact.
Neurologic:. No localized or sensory deficits. Normal profound reflexes. Mental status intact. Normal profound reflex.
Clear predominant manifestations of right-sided failure: increased jugular venous pressure, peripheral edema, ascites, and hepatomegaly.

Chest x-ray: marked cardiomegaly (++++) with absence of pulmonary congestion.