Bradycardia, Renal Failure, Atrioventricular Nodal Blockade, Shock, and Hyperkalemia (BRASH) Syndrome Associated With Baclofen and Diazepam

Bradycardia, renal failure, atrioventricular nodal blockade (AVNB), shock, and hyperkalemia (BRASH) syndrome is a relatively recently recognized clinical entity that can result in life-threatening complications. Although AVNB caused by beta blockers and calcium channel blockers is central to disease onset, baclofen and diazepam have not previously been implicated. We report a case of BRASH syndrome triggered by the combination of baclofen and diazepam, without involvement of other known AVNB agents. A 60-year-old male with cerebral palsy and chronic kidney disease was found unresponsive. He had started minocycline for a urinary tract infection five days prior and had not consumed food on the day of presentation. Initial vital signs revealed bradycardia, hypotension, and hypothermia. Laboratory testing showed mild hyperkalemia. Bradycardia and hypotension improved gradually with fluid resuscitation. Based on the constellation of findings, including bradycardia, renal failure, hypotension, and hyperkalemia, the patient was retrospectively diagnosed with BRASH syndrome associated with baclofen and diazepam, the only medications he was taking with AVNB properties. Although his renal function deteriorated and hyperkalemia progressed 15 days after onset, appropriate dietary management and fluid intake successfully prevented recurrence. This case demonstrates that the combination of baclofen and diazepam can induce BRASH syndrome. Maintaining adequate hydration proved effective in preventing recurrence, despite worsening renal function and increasing hyperkalemia. In patients with limited renal reserve who present with bradycardia and hyperkalemia while receiving baclofen and diazepam, BRASH syndrome should be considered.