Brugada Pattern Manifesting During Hyperkalemia, Diabetic Ketoacidosis, and Acute Alcohol Intoxication

Abstract

Patient: Male, 28-year-old Final Diagnosis: Alcohol intoxication • Brugada pattern • diabetic ketoacidosis • hyperkalemia Symptoms: Encephalopathy Medication:— Clinical Procedure: — Specialty: Cardiology Objective: Rare disease Background: Brugada syndrome is a rare ion channelopathy that can lead to sudden cardiac death and lethal arrhythmias in patients without a structural cardiac defect, the most common of which being the gain-of-function mutation of the SCN5a sodium ion channel involving phase 0 of the cardiac action potential. In 2012, BrS electrocardiogram findings were redefined and classified as either congenital Brugada syndrome (BrS) or Brugada pheno-copies (BrP). Several etiologies of BrP have been reported, such as metabolic derangements, electrolyte abnormalities, cardiovascular diseases, and pulmonary embolism. Case Report: A 28-year-old man presented to the Emergency Department unresponsive. An initial ECG taken by Emergency Medical Services (EMS) was interpreted as a STEMI. An initial ECG in the ED showed a Brugada type I ECG pattern in leads V1-V2 and hyperacute T wave abnormalities, among other findings. Additionally, the patient had a serum potassium level of 9 mmol/L, glucose level of 1375 mmol/L, and peak cardiac troponin-I of 20.452 μg/L. All underlying medical conditions were stabilized, electrolyte and metabolic abnormalities were corrected, and subsequent normalization of electrocardiographic findings was achieved. Conclusions: Distinguishing congenital Brugada syndrome from Brugada phenocopies can be difficult, especially when patients present to the ED with severe underlying conditions. Several factors can be used to direct clinical suspicion towards one or the other; however, confirmation may require EP studies and further tests. In this case, the following findings were suggestive of BrP: presence of an identifiable underlying abnormality, correction of the underlying condition resolves the ECG pattern, and the absence of family history of sudden cardiac death.

Brugada Syndrome: Warning of a Systemic Condition?

“…However, so much is not known about the mechanism of BrS, and given the fact that BrS has historically been defined more for what it is not than for what it is, it may actually be premature to discount ST segment elevations occurring in the presence of electrolyte imbalances in the quest to unveil the mechanism of BrS (41). Several studies have described hypokalemia (97)(98)(99), hyperkalemia (100)(101)(102)(103)(104), or hypercalcemia (105)(106)(107) in association with the BrS ECG pattern, or in association with an elevated ST segment that appears identical to the BrS pattern. Diseases related to these conditions, such as Gitelman syndrome, which results in potassium depletion, usually attributed to the SLC12A3 gene, can lend new candidate genes to the field of BrS (108).…”

“…Ion channel dysfunction has been associated with diabetes mellitus (DM), leading to the development of a heart disorder called diabetic cardiomyopathy (179,180), characterized by contractile dysfunction, abnormal cardiac electrical activity, mitochondrial dysfunction, arrhythmia, and sudden cardiac death (159,160). Several patients affected by DM have been reported to exhibit the BrS ECG pattern, whether it was considered "true BrS" or a "BrS phenocopy" (104,(181)(182)(183)(184), although a difference between "true BrS" and "BrS phenocopy" may not actually exist (41). A case report described a 16-yearold boy affected by DM and a mutation in the GPD1L gene who died suddenly during the night (185).…”

A rare case with melatonin‐induced on top of alcohol intoxication Brugada type 2 pattern

“…A Brugada phenocopy (BrP) is a condition where there is an identical ECG pattern to a congenital BrS, but this is due to other reversible etiologies like electrolyte imbalance and some clinical conditions such as myocardial infarction 2 . A quick resolution of the Brugada ECG pattern was noted upon treating the underlying factors 3 …”

“…2 A quick resolution of the Brugada ECG pattern was noted upon treating the underlying factors. 3 Here is a case that has never been reported in the literature review before which is Brugada pattern (BP) type 2 seen on an ECG following concomitant ethanol and melatonin overdose in a patient who had no known history of BrS before presented to the emergency department (ED).…”