Beyond Digoxin Toxicity: A Fatal Case of BRASH Syndrome Triggered by Community-Acquired Pneumonia

Bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia (BRASH) syndrome is a rare, life-threatening clinical condition caused by the synergistic interaction between hyperkalemia, renal dysfunction, and AV nodal blocking agents, resulting in severe bradycardia and hemodynamic instability.Early recognition is often challenging due to its nonspecific presentation.We report the case of an 82-year-old man with atrial fibrillation, ischemic heart disease, congestive cardiac failure, chronic kidney disease, and chronic digoxin therapy who presented with abdominal pain, confusion, dizziness, hypotension, and profound bradycardia.Investigations demonstrated severe hyperkalemia, acute kidney injury on top of chronic kidney disease, hyponatremia, and electrocardiographic changes consistent with hyperkalemia.Initial differential diagnoses included mesenteric ischemia, adrenal insufficiency, and digoxin toxicity; however, imaging excluded bowel ischemia, cortisol levels were normal, and serum digoxin at the therapeutic level.Community-acquired pneumonia complicated by sepsis was identified as the precipitating trigger for BRASH syndrome.Despite intensive treatment, including hyperkalemia management, isoprenaline infusion, antibiotics, corticosteroids, and supportive care, the patient's condition progressively deteriorated, culminating in multiorgan failure and death shortly afterward.This case highlights the diagnostic complexity of BRASH syndrome and emphasizes the importance of early recognition and targeted management to interrupt the vicious cycle and improve clinical outcomes.