Bradycardia, Renal Dysfunction, Atrioventricular Nodal Blockade, Shock, and Hyperkalemia (BRASH) Syndrome: A Case Report Highlighting the Importance of Early Recognition and Management.

BRASH syndrome, characterized by bradycardia, renal dysfunction, atrioventricular nodal blockade, shock, and hyperkalemia, is a newly defined condition that can lead to significant morbidity and mortality if not promptly recognized and treated. The triggers for this syndrome often include medication interactions, dehydration, and nephrotoxic insults, particularly in older patients with limited renal reserve and cardiovascular disease. In this report, we present the case of an 88-year-old female with multiple comorbidities who exhibited symptoms of prostration, bradycardia, hypotension, and altered mental status, along with laboratory findings (hyperkalemia and renal dysfunction) consistent with BRASH syndrome, triggered by hypovolemia associated with a urinary tract infection. Immediate treatment must focus on correcting hyperkalemia, providing hemodynamic support for bradycardia and hypotension, and administering guided fluid resuscitation. Prompt identification and management of the syndrome can prevent the need for invasive interventions, such as pacemaker insertion and dialysis. Healthcare professionals should be vigilant in considering BRASH syndrome, especially in older patients with cardiac disease, limited renal function, and those on medication regimens that include AV-nodal blocking agents, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and potassium-sparing diuretics. This case report emphasizes the importance of clinical suspicion and the initiation of timely treatment to interrupt the cycle of BRASH syndrome and improve patient outcomes.

Giant Right Atrium: An Extreme Structural Damage Case Due to Rheumatic Heart Disease.

Giant right atrium (RA) is a rare finding in adults. We report a case of a 53-year-old female with rheumatic heart disease (RHD) previously submitted to two mitral valve replacements. She presented at the emergency room with signs of heart failure. Image studies revealed gross cardiomegaly. Transthoracic echocardiogram showed torrential tricuspid regurgitation, with right chambers enlargement. At chest tomography, the estimated right atrium volume was 1,200 mL. The patient was treated with intravenous diuretics and multiple paracentesis, as well as referred to heart transplantation. Physicians should be aware of this extreme outcome, which can lead to life-threatening complications such as atrial fibrillation and thromboembolism.