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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 3  |  Issue : 4  |  Page : 142-144

Hyperkalemia-induced brugada phenocopy complicated with supraventricular tachycardia: A case report of rare electrocardiogram manifestation


Department of Cardiovascular, First Affiliated Hospital of Medical College, Xi'an Jiaotong University; Ministry of Education, Xi'an, China

Date of Web Publication19-Dec-2018

Correspondence Address:
Jianqing She
Department of Cardiovascular, First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710048
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cp.cp_22_18

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  Abstract 


In rare clinical cases, hyperkalemia can present with a type 1 Brugada EKG pattern, which correlates with fatal cardiac arrhythmia but could be resolved after hyperkalemia lowering treatment. In this case report, we present a rare EKG manifestation of hyperglycemia induced Brugada phenocopy complicated with supraventricular tachycardia. Early detection and quick diagnose for this kind of EKG presentation is crucial for making prompt and accurate treatment.

Keywords: Brugada, electrocardiogram, hyperkalemia


How to cite this article:
Guo M, Deng Y, Wu Y, She J. Hyperkalemia-induced brugada phenocopy complicated with supraventricular tachycardia: A case report of rare electrocardiogram manifestation. Cardiol Plus 2018;3:142-4

How to cite this URL:
Guo M, Deng Y, Wu Y, She J. Hyperkalemia-induced brugada phenocopy complicated with supraventricular tachycardia: A case report of rare electrocardiogram manifestation. Cardiol Plus [serial online] 2018 [cited 2019 Jan 23];3:142-4. Available from: http://www.cardiologyplus.org/text.asp?2018/3/4/142/247951




  Introduction Top


Hyperkalemia is a common clinical problem. Severe hyperkalemia results in a widening of the QRS complex, and the ECG complex can evolve to a sinusoidal shape. Brugada syndrome (BrS) is a genetic disorder in which the electrical activity within the heart is disturbed. The pattern seen on the ECG includes ST elevation in leads V1-V3 with a right bundle branch block (RBBB) appearance. In a minority of patients, hyperkalemia can also present with type I Brugada pattern in the EKG. This EKG presentation often occurs in severely ill patients with serum potassium concertation >7.0meq/L and is associated with fatal arrhythmia and mortality. In this report, we discussed a patient with rare EKG manifestation of hyperglycemia induced Brugada phenocopy complicated with supraventricular tachycardia.


  Case Report Top


A 54-year-old male was admitted to hospital for recurrent cough and shortness of breath, which started 3 months previously and became excruciating for the past 10 days. He was diagnosed with Hodgkin's lymphoma 1-year prior and received chemotherapy regularly. He denied any history of syncope in the past. Family history was negative for sudden cardiac death or cardiac problem. Initial arterial blood gas analysis revealed pH 7.429, PO2 56.8 mmHg, PCO2 40.5 mmHg, BE 9.1 mol/L, HCO3-26.3 mmol/L, K+ 4.3 mmol/L (3.5–4.5 mmol/L), and Lac 1.2 mmol/L. Serum K+ was 3.79 mmol/L (3.5–5.3 mmol/L), and chest CT indicated interstitial pneumonia. Admission electrocardiogram (EKG) showed sinus rhythm with heat rate of 75 beats per/min (bpm), axis left-deviated and inverted T wave from V1 to V6 leads [Figure 1].
Figure 1: Electrocardiogram in initial hospitalization without hyperkalemia. Sinus rhythm with heat rate of 75 beats/min (bpm), axis left-deviated and inverted T wave from V1 to V6 leads

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A diagnose of pulmonary fibrosis complicated with infection and Type I respiratory failure was made, and antibiotics as well as a noninvasive ventilator were administrated. Three days after the initial hospitalization, the patient's cardiac monitoring suddenly showed tachycardia. EKG at this time showed tachycardia with the heart rate of 160 bpm, along with coved type ST elevation and a T-wave inversion in precordial leads V1 to V4 (Type 1 Brugada pattern) [Figure 2]. EKG 5 min later showed typical Type I Brugada pattern with the heart rate of 83 bpm [Figure 3]. Arterial blood gas analysis at this time showed pH 7.082, PO2 79.9 mmHg, PCO2 54.5 mmHg, BE 12.5 mol/L, HCO3 - 14.40 mmol/L, K+ 5.80 mmol/L, and Lac 5.1 mmol/L. Potassium lowering treatment as well as resuscitation was promptly initiated. However, the patient died eventually due to severe infection and respiratory failure.
Figure 2: Electrocardiogram showing tachycardia with the heart rate of 160 bpm, along with ≥2 mm coved type ST elevation and a T-wave inversion in precordial leads V1 to V4 (type 1 Brugada pattern)

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Figure 3: Electrocardiogram showing ≥2 mm coved type ST elevation and a T-wave inversion in precordial leads V1 to V4 (Type 1 Brugada pattern) with the heart rate of 83 bpm

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  Discussion Top


Brugada syndrome (BrS) is an inherited disease characterized by increased risk of sudden cardiac death and abnormal EKG pattern.[1] There are three types of Brugada patterns based on the EKG presentation: (i) Type 1 Brugada presents as a “coved type” pattern, which means the elevated ST segment (e2 mm) descending with an upward convexity to an inverted T wave; (ii) Type 2 Brugada has a “saddle back” ST-T-wave configuration with at least 2 mm J-point elevation and at least 1 mm ST elevation. The T-wave can be either positive or biphasic; and (iii) Type 3 Brugada also has a “saddle back” ST-T wave but without elevation of J point or ST segment.[2] BrS remains the major cause of sudden unexplained death syndrome.[3]

Hyperkalemia is a common clinical problem, which includes an elevated level of potassium (K+) (i.e., over 5.5 mEq/L) in the blood serum.[4] The cause for hyperkalemia generally includes impaired urinary potassium excretion, inhibition of the renin-angiotensin-aldosterone axis, and excessive potassium release.[5] The most serious manifestations of hyperkalemia are paralysis, cardiac conduction abnormalities, cardiac arrhythmias, or even sudden cardiac arrest. As for EKG findings, tall-peaked T wave with a shorted QT interval is the usual initial presentation. With the increasing serum potassium level follows prolonged PR interval and QRS duration. Moreover, finally, a widened sine-wave pattern appears while P-wave disappears. In a minority of patients, hyperkalemia can also present with type I Brugada pattern in the EKG, which often occurs in severely ill patients with serum potassium concentration of >7.0 meq/L and predicts high incidence of fatal arrhythmia and mortality. AbsentPwaves and widened QRS complex can sometimes help distinguish hyperkalemia from Brugada pattern in those patients.[6]

In the present case, hyperkalemia was the complication secondary to severe infection and respiratory failure. While EKG for this patient showed Type I Brugada pattern, serum potassium is only mildly elevated. Meanwhile, supraventricular tachycardia concurred with Type I Brugada, further complicating EKG recognition and requiring careful clinical assessment. For those patients with hyperkalemia and Type I Brugada pattern, careful clinical assessment and quick serum potassium level detection are crucial for prompt clinical treatments.


  Conclusion Top


In rare clinical cases, hyperkalemia can present with a Type 1 Brugada EKG pattern, which correlates with fatal cardiac arrhythmia but could be resolved after hyperkalemia lowering treatment. Early detection and quick diagnose for this kind of EKG presentation is crucial for making prompt and accurate treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This paper was supported by the National Natural Science Foundation of China (81570406) and the Fundamental Research Funds for the Central Universities in China (1191329724).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Adler A. Brugada syndrome: Diagnosis, risk stratification, and management. Curr Opin Cardiol 2016;31:37-45.  Back to cited text no. 1
    
2.
Refaat MM, Hotait M, Scheinman M. Brugada syndrome. Card Electrophysiol Clin 2016;8:239-45.  Back to cited text no. 2
    
3.
Ahmed I, Nuri MM, Khan Orekzai MA, Hiba-tul-Waheed. Brugada syndrome: An electrical storm without warning. J Coll Physicians Surg Pak 2015;25 Suppl 1:S6-7.  Back to cited text no. 3
    
4.
Weiss JN, Qu Z, Shivkumar K. Electrophysiology of hypokalemia and hyperkalemia. Circ Arrhythm Electrophysiol 2017;10. pii: e004667.  Back to cited text no. 4
    
5.
Liu R, Chang Q, Liu A. Permanent atrial fibrillation: Special electrocardiogram in hyperkalemia. Int J Cardiol 2016;215:519-20.  Back to cited text no. 5
    
6.
Dendramis G, Paleologo C, Sgarito G, Giordano U, Verlato R, Baranchuk A, et al. Anesthetic and perioperative management of patients with Brugada syndrome. Am J Cardiol 2017;120:1031-6.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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