Autolytic attempt mimicking Brugada type 1 electrocardiogram pattern due to flecainide toxicity. A case report

BACKGROUND: Brugada phenocopies are a group of heterogeneous disorders that mimic Brugada syndrome (BrS) electrocardiogram (ECG) changes elicited by reversible clinical conditions. We report a novel case on flecainide toxicity causing an ECG signature of Brugada type 1 pattern in the paediatric age. CASE SUMMARY: A 13-year-old Caucasian boy with untreated attention-deficit/hyperactivity disorder referred to the Pediatric Emergency Department (PED) after unknown antiarrhythmic drug overdose. He deliberately ingested 10 tablets from a labelled white box of a 100-mg single dose. The ECG showed a coved-type ST-segment elevation in right precordial leads and prolongation of PR segment with a QTc limit interval. Values of troponins gradually increased and echocardiogram was normal. The altered ECG pattern was explained by the stabilizing membrane effect of flecainide involving the inhibition of rapid Na(+) channels. After offending drug removal, regression of ECG changes was observed and no cardiac events were documented during follow-up. DISCUSSION: Flecainide-induced Brugada type 1 ECG pattern may occur in patients with no evidence of genetic susceptibility receiving a toxic dosage of this drug. With increasing dose, its action on conduction pathways manifests as prolongation of PR interval and QT and QRS complex duration and may cause BrS mimicry. A detailed clinical history considering symptoms and ECG findings may support early-raised suspicion for flecainide ingestion. The therapeutic approach implies primary detoxification, prevention of potential triggers, and management of eventual cardiotoxicity events. Finally, risk stratification for BrS should be always measured according to the clinical scenario and surveillance considered in a timely manner.