Drug-Induced Type 1 Brugada Pattern: A Case Report

Brugada syndrome is a rare genetic disorder, classified as an autosomal dominant inherited cardiac sodium channelopathy. It is associated with a high incidence of syncope and sudden death due to ventricular tachycardia or ventricular fibrillation in patients with structurally normal hearts. This report presents the case of a 33-year-old male who experienced recurrent syncopal episodes over the course of a year. The episodes resembled seizure activity, with associated memory loss of the events and no preceding warning symptoms. The patient was ultimately diagnosed with a drug-induced type 1 Brugada pattern, triggered by the antidepressant dosulepin. His medical history was significant for psychiatric conditions, including depression and previous suicide attempts, but there was no history of known cardiac conditions or epilepsy, nor any family history of sudden cardiac death. The patient denied using illicit substances or consuming significant amounts of alcohol. The physical examination was unremarkable. Investigations revealed a troponin level of less than 3.3 ng/mL, and an ECG showed cove-shaped ST-segment elevation with inverted T-waves in leads V1-V2, consistent with a type 1 Brugada pattern. Imaging, including a CT head scan, chest X-ray, echocardiogram, and blood tests (full blood count, electrolytes, and CRP), were all within normal limits. A neurological assessment suggested that the syncopal episodes were unlikely to be of neurological or epileptic origin, with a normal EEG. The cardiology team reviewed the case and agreed that the ECG findings were consistent with a type 1 Brugada pattern, with the syncopal episodes likely being caused by transient arrhythmias. Upon reviewing the patient's medications, dosulepin, a tricyclic antidepressant, was identified as the probable trigger for the exacerbation of his underlying Brugada pattern. A psychiatry consultation was recommended to reassess this medication and explore alternative treatments. Dosulepin was discontinued and replaced with mirtazapine. Telemetry monitoring (24-hour ECG) showed normal sinus rhythm with no further Brugada pattern.