Brugada syndrome in childhood: a potential fatal arrhythmia not always recognised by paediatricians. A case report and review of the literature

Unintentional Cocaine Exposure and Brugada Syndrome: A Case Report

This case report describes a 16-month-old child with an accidental ingestion of cocaine. The clinical presentation, diagnostic reasoning, hospital course, and subsequent follow-up are discussed in this report. In 2018, there were 2.1 million human poison exposure calls to U.S. Poison Control Centers, with the highest incidence of calls for children aged 1-2 years. The substances with the largest number of deaths across all age groups included sedatives, sleeping medications, stimulants, street drugs, opioids, and alcohol. The child in this case report is a male who presented to the emergency department with altered mental status. When his urine drug screen resulted positive for cocaine, a social service consult was initiated, and the child was admitted to the intensive care unit for monitoring and supportive care. His electrocardiogram showed a Brugada rhythm. This case report highlights the incidence of accidental drug ingestions by children and a rare but potentially fatal cardiac arrhythmia.

Syncope and Palpitations: A Review

Syncope and palpitations are common complaints for patients presenting to their primary care provider. They represent symptoms that most often have a benign etiology but rarely can be the first warning sign of a serious condition, such as arrhythmias, structural heart disease, or noncardiac disease. The history, physical examination, and noninvasive testing can, in most cases, distinguish benign from pathologic causes. This article introduces syncope and palpitations, with emphasis on the differential diagnoses, initial presentation, diagnostic strategy, and various management strategies.

Adolescent Seizure in the Emergency Department Due to Concomitant Brugada Syndrome

Brugada syndrome is an increasingly discussed entity in the emergency medicine and cardiology literature. However, there are few cases reported in the pediatric population. Seizure is a presentation common to pediatric emergency departments. This case report describes the clinical course, workup, and differential diagnosis of a 15-year-old male adolescent with first-time seizure and Brugada pattern on electrocardiogram. A brief review of the literature follows the case presentation.

The Impending Dilemma of Electrocardiogram Screening in Athletic Children

Sudden cardiac death (SCD) affects 2/100,000 young, active athletes per year of which 40% are less than 18 years old. In 2004, the International Olympic Committee accepted the Lausanne Recommendations, including a 12-lead electrocardiogram (ECG), as a pre-participation screening tool for adult Olympic athletes. The debate on extending those recommendations to the pediatric population has recently begun. The aims of our study were to highlight the characteristics of the young athlete ECG, phenotypical manifestations of SCD-related disease in children, and challenges of implanting ECG screening in athletic children. A systematic review of the literature is performed. We searched available electronic medical databases for articles relevant to SCD, ECG, silent cardiac diseases, and athletic children. We focused on ECG screening and description in a pediatric population. We identified 2240 studies. Sixty-two relevant articles and one book were selected. In children, prepubertal ECG and the ECG phenotype of most SCD-related diseases differ notably from adults. The characteristics of the prepubertal ECG and of the phenotypical manifestation of SCD-related disease in children will result in less specific and less sensitive ECG-based screening programs. Those limitations advise against extending the adult recommendation to children, without further studies. Until then, history and physical exam should remain the cornerstone of screening for SCD-related pathologies in children.

The electrocardiographic manifestations of arrhythmogenic right ventricular dysplasia

The ECG is abnormal in most patients with arrhythmogenic right ventricular dysplasia (ARVD). Right ventricular parietal block, reduced QRS amplitude, epsilon wave, T wave inversion in V1-3 and ventricular tachycardia in the morphology of left bundle branch block are the characteristic changes that reflect the underlying genetic predetermined pathology and pathoelectrophysiology. Recognizing the characteristic ECG changes in ARVD will be of help in making a correct diagnosis of this rare disease.

Feasibility and outcomes of ajmaline provocation testing for Brugada syndrome in children in a specialist paediatric inherited cardiovascular diseases centre

Objectives

Brugada syndrome (BrS) is an inherited arrhythmia syndrome that causes sudden cardiac death in the young. The class Ia antiarrhythmic ajmaline can be used to provoke the diagnostic ECG pattern. Its use has been established in adults, but little data exist on the ajmaline provocation test in children. This study aims to determine the safety and feasibility of ajmaline provocation testing in a large paediatric cohort in a specialist paediatric inherited cardiac diseases centre.

Methods

98 consecutive ajmaline tests were performed in 95 children between September 2004 and July 2012 for family history of BrS (n=46 (48%)); family history of unexplained sudden cardiac death (n=39 (41%); symptoms with suspicious ECG abnormalities (n=9 (10%)). Three patients were retested with age, due to the possibility of age-related penetrance. ECG parameters were measured at baseline and during maximal ajmaline effect.

Results

The mean patient age was 12.55 years, 43% were female. Nineteen patients (20%) had a positive ajmaline test. There were no arrhythmias or adverse events during testing. Ajmaline provoked significant prolongation of the PR, QRS and QTc in all patients. Mean follow-up was 3.62 years with no adverse outcomes reported in any patients with BrS. There were no predictors of a positive ajmaline provocation test on multivariable analysis. One patient who tested negative at 12 years of age, subsequently tested positive at 15 years of age.

Conclusions

Ajmaline testing appears safe and feasible in children when performed in an appropriate setting by an experienced team. Test positivity may change with age in individuals, suggesting that the test should be repeated in the late teenage years or early adulthood.

Aborted sudden cardiac death in adolescent

Sudden cardiac death is rare in children and adolescents but accounts for 19% to 30% of sudden deaths until 21 years of age. Fatal ventricular arrhythmias are usual common pathways in such tragic events, and underlying etiologies include cardiac ion channelopathies in majority of cases. We present a case of aborted sudden cardiac death in field, resuscitated successfully, and a clinical event in the pediatric emergency department that led to the diagnosis of the underlying rare condition.

Childhood brugada syndrome in two korean families

Since the first descriptions of Brugada as a new clinical entity defined by sudden cardiac death in patients with typical electrocardiogram (ECG) patterns, Brugada syndrome (BS) has been increasingly diagnosed. This syndrome is known as a disease that is inherited via an autosomal dominant trait, and the SCN5A mutation has been found in 20-25% of BS patients. Because BS primarily manifests in adulthood, little information is available on BS during childhood. Although there have been several reports on adult BS in Korea, pediatric BS has not been reported. Herein, we report on childhood BS in two families. One infantile BS patient and his family had a novel SCN5A mutation (c.4035G>T, p.W1345C, heterozygote) in domain III of the sodium channel.

The Brugada syndrome

PURPOSE OF REVIEW

The Brugada syndrome has been an area of intensive investigation since its earliest description in 1992, both on a clinical and on a basic research level. In this review, we will focus on recent achievements in the molecular dissection of the disease pathophysiology and on large multicenter studies dealing with prognostic markers and the natural history of the Brugada syndrome.

RECENT FINDINGS

In the past year, two additional genetic pathways have been associated with the disease. Also, an inflammatory or infectious etiology has recently been linked with the Brugada syndrome. The debate on the predictive role of programmed electrical stimulation is still ongoing. Very recently, large follow-up studies questioned the prognostic role of programmed electrical stimulation in this disease.

SUMMARY

Knowledge on the genetic determinants of the Brugada syndrome remains limited. Therefore, the management and the risk stratification of patients should be performed on a clinical basis. Sufficient evidence exists to reassure clinicians who feel reluctant to include programmed electrical stimulation in the risk stratification strategy of asymptomatic Brugada syndrome patients.