Rare presentation of BRASH syndrome with hypoglycemia and altered mental status

Abstract

Background: BRASH syndrome (bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia) is a rare clinical condition with potentially severe outcomes. Patients with BRASH syndrome can present with diverse signs and symptoms and are usually in critical condition, but if recognized early, the syndrome is treatable and may have a favorable prognosis.

Case presentation: This case study presents a 74-year-old patient with a history of multiple chronic conditions who was brought to the emergency department with a suspected cerebrovascular accident, altered mental status, and bradycardia. A head computed tomography scan was unremarkable but laboratory results showed hyperkalemia, acidosis, and renal failure with concomitant progressive hypoglycemia. The patient was diagnosed with a BRASH syndrome characterized by a vicious cycle of atrioventricular nodal blockade induced by the potentiated effect of beta-blockers or calcium channel blockers, in combination with progressive hypoglycemia due to the suspected accumulation of anti-diabetic medications, which influenced the presentation and initial triage in the emergency department. She was admitted to the intensive care unit for further management, where she continued to improve and was ultimately discharged in a relatively stable condition.

Conclusion: This case study highlights the importance of considering rare and atypical presentations of medical conditions, particularly in elderly patients who may have multiple comorbidities. Early recognition and prompt management of such cases are crucial for improving patient outcomes.

Keywords: BRASH; Bradycardia; Hyperkalemia; Hypoglycemia.

Fig. 1

ECG obtained by emergency medical services showing atrial fibrillation with a right bundle branch block and slow ventricular response, heart rate 30 beats/min

Fig. 2

ECG obtained at the emergency department showing atrial fibrillation with a right bundle branch block and slow ventricular response, heart rate 45 beats/min after administration of 1 mg of Atropine