Patients who are diagnosed with Brugada syndrome (BS) usually experience sudden cardiac arrest (SCA) and arrhythmia when they have a high fever, consume alcohol, and, more frequently, during their night sleep. In some rare cases, an SCA can be seen depending on a possible vagal stimulus, such as eating a large bite of food. We describe a 9-year-old patient who had a sudden cardiac attack while he was eating a large hot dog. After successful resuscitation, a suspicious ST elevation in V2 was seen in his electrocardiographic evaluation. He was diagnosed with BS after the ajmaline test and an implantable cardioverter defibrillator was implanted. Vagal stimulus–dependent SCA after eating a large bite of food may be the first symptom of BS. For this reason, the electrocardiographic results of the children who had a cardiac arrest after eating a large meal with big bites should be evaluated in detail.
Sudden cardiac arrest (SCA) occurs in one-third of patients who have Brugada syndrome (BS). It may be the first or second clinical finding. In patients with BS, SCA usually does not occur because of exercise. These arrhythmia cases are usually seen in children who have a high fever. In adults, it occurs depending on high alcohol consumption and, more frequently, during their night sleep. In some rare cases, an SCA may be seen in patients with BS because of eating a large bite of food.1,2 No co-occurrence has been reported in children until now.
This study presents the case of a patient who had a sudden cardiac attack while eating a large hot dog. After successful resuscitation, he was diagnosed with BS and implanted with an implantable cardioverter defibrillator (ICD).
A 9-year-old male patient had syncope and cardiopulmonary arrest 1 month previously while he was eating a large hot dog at school. Ventricular fibrillation was seen during resuscitation. Then, the patient was defibrillated and resuscitated for 30 minutes. He was treated as an inpatient at another children’s intensive care service. He was sent to our clinic because of a suspicious ST elevation in V2 in his electrocardiograph (ECG) (Fig 1). No special disease was reported in his family history. His ECG, exercise stress test, and other biochemical analyses were normal. Any specific drug use was not reported. According to the result of the ajmaline test, a type 1 Brugada pattern was observed in his ECG and he was diagnosed with BS (Fig 2). A further electrophysiologic study (EPS) also was applied to the patient. Using a complete ventricular stimulation protocol, no significant or sustained arrhythmias were induced. An ICD was implanted in the patient. The patient’s family was screened. The patient has no family history of BS. The ECG results of the patient’s parents were normal; however, his brother had a suspicious ST elevation in V1–V2 when it was high level (second intercostal space). An ajmaline test was applied to the brother and he was also diagnosed with BS. Treatment was not given because he was asymptomatic. The patient and his brother were advised to avoid high fever, alcohol consumption, larger-size food items, and the drugs that trigger BS. The result of the patient’s genetic study is awaited.
BS is a heritable, life-threatening cardiac channelopathy characterized by either a complete or an incomplete right bundle branch block and ST-segment elevation in V1–V3 on an ECG.1 This study showed that 26 of 30 patients who had ventricular fibrillation had vagal stimulus–dependent arrhythmia during their sleep. Therefore, it can be concluded that vagal stimulus plays an important role in arrhythmia pathogenesis.3 A study also showed that the possibility of having a cardiac arrest was 7.7% in patients with BS who had already had a cardiac arrest, 1.9% in patients with syncope, and 0.5% in asymptomatic patients.4 It was assumed that the sensitivity of the drug provocation test was between 71% and 80% in the patients who had an SCN5A mutation. This percentage represented only 20% of the patients who had BS. In the BS cases without an SCN5A mutation, the sodium channel blocking test was 100% sensitive in the patients who survived SCA and had temporal type I ECG. High fever, alcohol, taking large bites from food, and drugs that trigger BS should be avoided when a typical BS ECG pattern is seen during the ajmaline test. The most important presymptoms are a spontaneous type I ECG pattern and inducible ventricular arrhythmia during evoked potentials in terms of prognosis and risk evaluation.1 Despite numerous studies, the role of EPS for reliable risk stratification in patients with BS still remains controversial.5,6 This is illustrated by the finding of a negative EPS in our case.
The automatic modulation in BS plays an important role in the occurrence of tonus ventricular arrhythmia.2 Food intake may affect the vagal activity. Nogami et al7 showed the ST elevation with glucose and insulin tests in patients with BS. They concluded that the serum concentrations of glucose and insulin increase after eating a large meal and this may cause an ST elevation. Ikeda et al2 showed that the characteristic ECG alterations increase in patients with BS after eating large bites of food. This study emphasized that eating large bites of food and the characteristic ECG alterations after SCA may be the causes of vagal stimulus–dependent SCA.
An SCA may be the first and most devastating clinical finding of BS, depending on a possible vagal stimulus after eating a large bite of food. It should be kept in mind that patients with BS may have characteristic ECG changes develop after eating a large bite of food and SCA. To be able to make a correct diagnosis, it is important to make an ECG evaluation in patients who had a cardiac attack. ICD implantation is important as a secondary protection for patients with BS who had a cardiac attack.
Dr Ozyilmaz conceptualized and designed the study, drafted the initial manuscript, designed the data collection instruments, and coordinated and supervised data collection at 2 of the 4 sites; Dr Akyol carried out the initial analyses, and reviewed and revised the manuscript; Dr Ergul critically reviewed the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.