Two Cases of BRASH Syndrome

Abstract

BRASH syndrome is a rare entity that is often underdiagnosed. Recently known in 2016, it falls within the scope of drug toxicity. BRASH syndrome consists of bradycardia, renal failure, shock, and hyperkalemia, secondary to atrioventricular node blocking drugs. We report two cases of BRASH syndrome in order to encourage the physician to think about it in front of bradycardia associated with hyperkalemia in chronic renal patients and to intensify the monitoring of renal insufficiency under atrio-ventricular node blocker. BRASH syndrome is a rare entity that is often underdiagnosed. Recently known in 2016, it falls within the scope of drug toxicity. BRASH syndrome consists of bradycardia, renal failure, shock, and hyperkalemia, secondary to atrioventricular node blocking drugs. We report two cases of BRASH syndrome in order to encourage the physician to think about it in front of bradycardia associated with hyperkalemia in chronic renal patients and to intensify the monitoring of renal insufficiency under atrio-ventricular node blocker.

The first case was a 59-year-old man, hypertensive-diabetic, suffering from a stage IV chronic renal disease not dialyzed, having taken as antihypertensive drugs: Carvedilol 12.5 mg and Amlodipine 10 mg, presenting a picture of BRASH syndrome triggered by the intake of diuretic.

The second case was a 64-year-old hypertensive-diabetic man, presenting a mixed vascular and diabetic nephropathy stage V not dialyzed, under Carvedilol 12,5 mg and Amlodipine 10 mg making a picture of shock and severe bradycardia with aggravation of a hyperkalemia labeled as BRASH syndrome on bacterial pneumonia.

In both cases we initiated medical treatment of hyperkalemia with emergency administration of atropine and use of the positive inotropic substance Dobutamine. Atrioventricular node blocking drugs were discontinued. Haemodialysis was indicated but was not available for the first case for financial reasons. The evolution was fatal for the first case on a picture of refractory cardiogenic shock. On the other hand, it was favourable for the second case with normalization of heart rate and hemodynamic status of the patient and biologically a normalization of the kalemia.