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

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

Brugada syndrome (BrS), a genetically inherited ion channelopathy, has been linked to a considerable number of unexplained sudden cardiac deaths in patients without structural heart defects, and Brugada phenocopy (BrP) is a condition where there is an identical electrocardiogram (ECG) pattern to a congenital BrS, but this is due to other reversible etiologies. A 37-year-old male patient with a documented history of hypertension presented with vomiting after taking 43, 10 mg, melatonin pills and binge drinking locally made alcohol 2 days before. ECG showed right ventricular conduction delay with a "saddleback" appearance, with the J point elevated more than 2 mm and the terminal portion of the ST-segment elevated more than 1 mm in leads V1 and/or V2. Which returned to normal after a few hours. The association between the use of melatonin and the finding of the Brugada pattern (BP) in a patient with normal heart structure or abnormal ECGs has been documented in much literature, and although no official melatonin dosage is recommended for adults, melatonin has been reported to cause and protect from arrhythmias through different mechanisms. In our patient, after alcohol intoxication was ruled out as a cause, melatonin was the only significant risk factor related to his ECG findings. The BP can be found in patients with otherwise normal heart structure and ECG records, and an overdose of melatonin, which is used as an over-the-counter sleep medication, was found to be a possible cause of finding this pattern in these patients after excluding other known causes.

Brugada Syndrome: Warning of a Systemic Condition?

Brugada syndrome (BrS) is a hereditary disorder, characterized by a specific electrocardiogram pattern and highly related to an increased risk of sudden cardiac death. BrS has been associated with other cardiac and non-cardiac pathologies, probably because of protein expression shared by the heart and other tissue types. In fact, the most commonly found mutated gene in BrS, SCN5A, is expressed throughout nearly the entire body. Consistent with this, large meals and alcohol consumption can trigger arrhythmic events in patients with BrS, suggesting a role for organs involved in the digestive and metabolic pathways. Ajmaline, a drug used to diagnose BrS, can have side effects on non-cardiac tissues, such as the liver, further supporting the idea of a role for organs involved in the digestive and metabolic pathways in BrS. The BrS electrocardiogram (ECG) sign has been associated with neural, digestive, and metabolic pathways, and potential biomarkers for BrS have been found in the serum or plasma. Here, we review the known associations between BrS and various organ systems, and demonstrate support for the hypothesis that BrS is not only a cardiac disorder, but rather a systemic one that affects virtually the whole body. Any time that the BrS ECG sign is found, it should be considered not a single disease, but rather the final step in any number of pathways that ultimately threaten the patient's life. A multi-omics approach would be appropriate to study this syndrome, including genetics, epigenomics, transcriptomics, proteomics, metabolomics, lipidomics, and glycomics, resulting eventually in a biomarker for BrS and the ability to diagnose this syndrome using a minimally invasive blood test, avoiding the risk associated with ajmaline testing.