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Unusual Presentation of a Common Diagnosis in a Patient With Chronic Kidney Disease

To identify the key insights or developments described in this article
1 Credit CME

A patient in their 40s presented to the emergency department with acute-onset breathlessness for 2 hours. The patient was known to have chronic kidney disease and was receiving regular hemodialysis. However, the patient had missed their last 2 dialysis sessions. There was no history of chest pain, palpitation, or cough with expectoration. The patient had bradycardia with a pulse rate of 52 beats/min and blood pressure of 160/100 mm Hg. A respiratory system examination revealed coarse crepitations on both lung fields. The 12-lead electrocardiogram (ECG) is presented in the Figure.

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The term Brugada phenocopy was first coined by Baranchuk et al1 in 2012. They also proposed classification and updated the definition of BrP. The term is used when:

There are many causes of BrP described in the literature, such as hyperkalemia, myocardial infarction, pulmonary embolism, inappropriate use of a high-pass filter, and yellow oleander poisoning.3 These have been classified into 6 etiological categories: metabolic conditions, mechanical compression, ischemia and pulmonary embolism, myocardial and pericardial disease, ECG modulation, and miscellaneous.2

The most common cause of BrP described in the literature is hyperkalemia. A PubMed search using the terms Brugada phenocopy and hyperkalemia yielded 24 results. However, when analyzing all the search results for Brugada phenocopy and electrocardiographic pattern, we found 34 reported cases of BrP due to hyperkalemia. Xu et al4 found that the mean (SD) potassium level of patients with BrP was 7.45 (0.89) mEq/L when they analyzed 27 cases of BrP induced by hyperkalemia. In the current patient also, the potassium value was closer to the mean range observed. They also reported that the mean (SD) age of patients presenting with BrP due to hyperkalemia was 53 (15) years. The estimated mean (SD) time of resolution was 7 (3) hours.

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Article Information

Corresponding Author: Gunaseelan Rajendran, MD, DNB, Department of Emergency Medicine, Aarupadai Veedu Medical College and Hospital, VOC St, 2nd Main Rd, Plot No. 1, Dhakshinamoorthy Nagar, Puducherry 605009, India (drrigs08tkmc@gmail.com).

Published Online: November 7, 2022. doi:10.1001/jamainternmed.2022.4716

Conflict of Interest Disclosures: None reported.

References
1.
Baranchuk  A , Nguyen  T , Ryu  MH ,  et al.  Brugada phenocopy: new terminology and proposed classification.   Ann Noninvasive Electrocardiol. 2012;17(4):299-314. doi:10.1111/j.1542-474X.2012.00525.xPubMedGoogle ScholarCrossref
2.
Anselm  DD , Baranchuk  A .  Brugada phenocopy: redefinition and updated classification.   Am J Cardiol. 2013;111(3):453. doi:10.1016/j.amjcard.2012.09.005PubMedGoogle ScholarCrossref
3.
Gunaseelan  R , Sasikumar  M , Aswin  K , Dhar  S , Balamurugan  N , Pillai  V .  Brugada phenocopy induced by consumption of yellow oleander seeds—a case report.   J Electrocardiol. 2020;62:107-109. doi:10.1016/j.jelectrocard.2020.07.014PubMedGoogle ScholarCrossref
4.
Xu  G , Gottschalk  BH , Anselm  DD ,  et al.  Relation of the Brugada phenocopy to hyperkalemia (from the International Registry on Brugada Phenocopy).   Am J Cardiol. 2018;121(6):715-717. doi:10.1016/j.amjcard.2017.12.008PubMedGoogle ScholarCrossref
5.
Neto  NO , Pilla  L , Oliveira  WS ,  et al.  Brugada phenocopy induced by recurrent hyperkalemia: more evidence for the reproducibility of a new phenomenon.   J Electrocardiol. 2018;51(3):402-404. doi:10.1016/j.jelectrocard.2018.02.017PubMedGoogle ScholarCrossref
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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

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