A 41-year-old man presented to the emergency department due to retrosternal chest pain and dyspnea, which had aggravated on exertion. He was a nonsmoker and denied trauma or drug abuse, but he had a history of HIV infection which was treated with tenofovir, emtricitabine, and efavirenz. Physical examination was unremarkable without Kussmaul sign or prominent jugular veins. Electrocardiogram revealed ST-segment elevations and PR-interval depressions in leads I, II, aVL, V3 to V6 with reciprocal ST-segment depression and PR-interval elevation in lead aVR corresponding to injury of subepicardial myocardium and atrium. Additionally, small positive deflections in the J-point region could be detected in leads II, aVL, V5 and V6 (Figure 1A). Laboratory tests showed: leukocytosis (white blood cell count, 13.23×109/l; reference range, 4.4–11.3×109/l), elevated C-reactive protein levels (19.1 mg/l; reference range, 0–5 mg/l), and elevated N-terminal pro-B-type natriuretic peptide level (221 pg/ml; reference range, 0–150 pg/ml) without elevated troponin T (7 pg/ml; reference range, 0–14 pg/ml) or D-dimer (<0.19 mg/l; reference range, 0–0.5 mg/l). Echocardiography showed mild pericardial effusion.

Figure 1. A – electrocardiogram of a 41-year-old man revealing ST-segment elevations and PR-segment depressions. Additionally, J-waves could be detected in leads II, aVL, V5, and V6 called stork leg sign; B – schematic QRS complex and J-wave reversed 180° with an illustration of a stork standing on one leg. Inverted R­ wave corresponds to the standing leg while the other leg is lifted to the stork’s body (inverted J point deflection); C – electrocardiogram of the same 41-year-old man recorded 1 month after the initial presentation without the baseline changes

J­ waves are a manifestation of early repolarization and are sometimes referred to as Osborn waves after their describer who studied the effect of hypothermia on the cardiac function in dogs.1 Besides hypothermia, J­ waves were described in other conditions such as hypercalcemia, Brugada syndrome, or early repolarization syndrome.2-4 In acute pericarditis, J­ waves are sometimes referred to as “stork leg sign” due to their pattern if the electrocardiogram is turned 180° whereby the QRS complex looks like a stork standing on one leg (inverted R­ wave) while the other leg is lifted to the stork’s body (inverted J­ point deflection) (Figure 1B). After initiation of ibuprofen 600 mg 3 times daily, the patient could be discharged home after 4 days with an uneventful recovery. No J­ waves were observed anymore on follow-up electrocardiograms 2 days after initial presentation and 1 month after discharge (Figure 1C).