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Vol. 19, No. 6, 2010
Issue release date: September 2010
Section title: Case Report
Open Access Gateway
Med Princ Pract 2010;19:485–489
(DOI:10.1159/000320309)

Brugada Syndrome with Aborted Sudden Cardiac Death Related to Liquorice-Induced Hypokalemia

Yorgun H.a · Aksoy H.a · Şendur M.A.b · Ateş A.H.a · Kaya E.B.a · Aytemir K.a · Oto A.a
Departments of aCardiology and bInternal Medicine, Hacettepe University, Ankara, Turkey
email Corresponding Author

Abstract

Objective: It was the aim of this study to report an aborted cardiac arrest due to ventricular fibrillation and electrocardiographic changes consistent with Brugada syndrome due to liquorice-induced hypokalemia. Clinical Presentation and Intervention: Ventricular fibrillation was witnessed in a 50-year-old woman who was admitted to our emergency department with a history of liquorice ingestion, a herbal product. After stopping liquorice ingestion, the Brugada-like electrocardiographic pattern changed progressively with potassium replacement. A diagnosis of Brugada syndrome was made after the ajmaline challenge test. The patient was discharged with an implantable cardioverter defibrillator and had an uneventfull follow-up. Conclusion: This report illustrates the importance of the investigation for herbal medications in the detailed history of a patient in the cases of electrolyte disturbances and the potential role of hypokalemia in the induction of malignant arrhythmia in Brugada syndrome.

© 2010 S. Karger AG, Basel


  

Key Words

  • Brugada syndrome
  • Cardiac arrest
  • Liquorice
  • Hypokalemia

References

  1. Brugada P: Brugada syndrome: an electrocardiographic diagnosis not to be missed. Heart 2000;84:1–2.
  2. Araki T, Konno T, Itoh H, Ino H, Shimizu M: Brugada syndrome with ventricular tachycardia and fibrillation related to hypokalemia. Circ J 2003;67:93–95.
  3. Veltmann C, Borggrefe M, Schimpf R, Wolpert C: Images in cardiovascular medicine. Yew causes Brugada ECG. Circulation 2009;119:1836–1837.
  4. Rouleau F, Asfar P, Boulet S, Dube L, Dupuis JM, Alquier P, Vicor J: Transient ST segment elevation in right precordial leads induced by psychotropic drugs: relationship to the Brugada syndrome. J Cardiovasc Electrophysiol 2001;12:61–65.
  5. Brugada P, Brugada J: Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. A multicenter report. J Am Coll Cardiol 1992;20:1391–1396.
  6. Antzelevitch C: The Brugada syndrome: diagnostic criteria and cellular mechanisms. Eur Heart J 2001;22:356–363.
  7. Stewart PM, Wallace AM, Valentino R, Burt D, Shackleton CH, Edwards CR: Mineralocorticoid activity of liquorice: 11-beta- hydroxysteroid dehydrogenase deficiency comes of age. Lancet 1987;ii:821–824.

    External Resources

  8. Sigurjonsdottir HA, Manhem K, Axelson M, Wallerstedt S: Subjects with essential hypertension are more sensitive to the inhibition of 11 beta-HSD by liquorice. J Hum Hypertens 2003;17:125–131.
  9. Krähenbühl S, Hasler F, Frey BM, Frey FJ, Brenneisen R, Krapf R: Kinetics and dynamics of orally administered 18 beta-glycyrrhetinic acid in humans. J Clin Endocrinol Metab 1994;78:581–585.
  10. Sigurjonsdottir HA, Franzson L, Manhem K, Ragnarsson J, Sigurdsson G, Wallerstedt S: Liquorice-induced rise in blood pressure: a linear dose response relationship. J Hum Hypertens 2001;15:549–552.
  11. Clyburn EB, DiPette DJ: Hypertension induced by drugs and other substances. Semin Nephrol 1995;15:72–86.
  12. Helfant RH: Hypokalemia and arrhythmias. Am J Med 1986;80:13–22.
  13. Notarstefano P, Pratola C, Toselli T, Ferrari R: Atrial fibrillation and recurrent ventricular fibrillation during hypokalemia in Brugada syndrome. Pacing Clin Electrophysiol 2005;28:1350–1353.

  

Author Contacts

Hikmet Yorgun, MD
Department of Cardiology
Hacettepe University Faculty of Medicine
TR–06100 Sıhhıye, Ankara (Turkey)
Tel. +90 312 305 1780, Fax +90 312 305 4137, E-Mail yorgunhikmet@yahoo.com

  

Article Information

Received: December 15, 2009
Revised: April 6, 2010
Published online: September 28, 2010
Number of Print Pages : 5
Number of Figures : 3, Number of Tables : 0, Number of References : 13

  

Publication Details

Medical Principles and Practice (International Journal of the Kuwait University Health Sciences Centre)

Vol. 19, No. 6, Year 2010 (Cover Date: September 2010)

Journal Editor: Owunwanne A. (Kuwait)
ISSN: 1011-7571 (Print), eISSN: 1423-0151 (Online)

For additional information: http://www.karger.com/MPP


Open Access License / Drug Dosage / Disclaimer

Open Access License: This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Objective: It was the aim of this study to report an aborted cardiac arrest due to ventricular fibrillation and electrocardiographic changes consistent with Brugada syndrome due to liquorice-induced hypokalemia. Clinical Presentation and Intervention: Ventricular fibrillation was witnessed in a 50-year-old woman who was admitted to our emergency department with a history of liquorice ingestion, a herbal product. After stopping liquorice ingestion, the Brugada-like electrocardiographic pattern changed progressively with potassium replacement. A diagnosis of Brugada syndrome was made after the ajmaline challenge test. The patient was discharged with an implantable cardioverter defibrillator and had an uneventfull follow-up. Conclusion: This report illustrates the importance of the investigation for herbal medications in the detailed history of a patient in the cases of electrolyte disturbances and the potential role of hypokalemia in the induction of malignant arrhythmia in Brugada syndrome.

© 2010 S. Karger AG, Basel


  

Author Contacts

Hikmet Yorgun, MD
Department of Cardiology
Hacettepe University Faculty of Medicine
TR–06100 Sıhhıye, Ankara (Turkey)
Tel. +90 312 305 1780, Fax +90 312 305 4137, E-Mail yorgunhikmet@yahoo.com

  

Article Information

Received: December 15, 2009
Revised: April 6, 2010
Published online: September 28, 2010
Number of Print Pages : 5
Number of Figures : 3, Number of Tables : 0, Number of References : 13

  

Publication Details

Medical Principles and Practice (International Journal of the Kuwait University Health Sciences Centre)

Vol. 19, No. 6, Year 2010 (Cover Date: September 2010)

Journal Editor: Owunwanne A. (Kuwait)
ISSN: 1011-7571 (Print), eISSN: 1423-0151 (Online)

For additional information: http://www.karger.com/MPP


Article / Publication Details

First-Page Preview
Abstract of Case Report

Received: 12/15/2009
Accepted: 4/6/2010
Published online: 9/28/2010
Issue release date: September 2010

Number of Print Pages: 5
Number of Figures: 0
Number of Tables: 0

ISSN: 1011-7571 (Print)
eISSN: 1423-0151 (Online)

For additional information: http://www.karger.com/MPP


Open Access License / Drug Dosage

Open Access License: This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Brugada P: Brugada syndrome: an electrocardiographic diagnosis not to be missed. Heart 2000;84:1–2.
  2. Araki T, Konno T, Itoh H, Ino H, Shimizu M: Brugada syndrome with ventricular tachycardia and fibrillation related to hypokalemia. Circ J 2003;67:93–95.
  3. Veltmann C, Borggrefe M, Schimpf R, Wolpert C: Images in cardiovascular medicine. Yew causes Brugada ECG. Circulation 2009;119:1836–1837.
  4. Rouleau F, Asfar P, Boulet S, Dube L, Dupuis JM, Alquier P, Vicor J: Transient ST segment elevation in right precordial leads induced by psychotropic drugs: relationship to the Brugada syndrome. J Cardiovasc Electrophysiol 2001;12:61–65.
  5. Brugada P, Brugada J: Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. A multicenter report. J Am Coll Cardiol 1992;20:1391–1396.
  6. Antzelevitch C: The Brugada syndrome: diagnostic criteria and cellular mechanisms. Eur Heart J 2001;22:356–363.
  7. Stewart PM, Wallace AM, Valentino R, Burt D, Shackleton CH, Edwards CR: Mineralocorticoid activity of liquorice: 11-beta- hydroxysteroid dehydrogenase deficiency comes of age. Lancet 1987;ii:821–824.

    External Resources

  8. Sigurjonsdottir HA, Manhem K, Axelson M, Wallerstedt S: Subjects with essential hypertension are more sensitive to the inhibition of 11 beta-HSD by liquorice. J Hum Hypertens 2003;17:125–131.
  9. Krähenbühl S, Hasler F, Frey BM, Frey FJ, Brenneisen R, Krapf R: Kinetics and dynamics of orally administered 18 beta-glycyrrhetinic acid in humans. J Clin Endocrinol Metab 1994;78:581–585.
  10. Sigurjonsdottir HA, Franzson L, Manhem K, Ragnarsson J, Sigurdsson G, Wallerstedt S: Liquorice-induced rise in blood pressure: a linear dose response relationship. J Hum Hypertens 2001;15:549–552.
  11. Clyburn EB, DiPette DJ: Hypertension induced by drugs and other substances. Semin Nephrol 1995;15:72–86.
  12. Helfant RH: Hypokalemia and arrhythmias. Am J Med 1986;80:13–22.
  13. Notarstefano P, Pratola C, Toselli T, Ferrari R: Atrial fibrillation and recurrent ventricular fibrillation during hypokalemia in Brugada syndrome. Pacing Clin Electrophysiol 2005;28:1350–1353.