Acute liver failure and hepatic encephalopathy in exertional heat stroke

Abstract

A 31-year-old man was brought to Accident & Emergency after collapsing during a race. On presentation, the patient had a temperature of 41.7°C (rectal). External cooling was started immediately. The patient was intubated in view of a Glasgow Coma Scale of 7 and was transferred to theintensive therapy unit. Laboratory results revealed an acute kidney injury, rhabdomyolysis, disseminated intravascular coagulopathy and acute liver failure. The patient was encephalopathic, jaundiced and difficult to sedate. His liver function continued to deteriorate with alanine aminotransferase (ALT) levels reaching 9207 U/L. King's Hospital Liver Centre, London was contacted for a possible liver transplant, and they advised an infusion of N-acetylcysteine. The following day liver function tests improved; thus, transplantation was not performed. The patient failed multiple sedation holds and required a tracheostomy. He continued to spike a fever. Despite no source of sepsis being found, the patient remained on broad spectrum antibiotics to cover for any potential infective causes until day 27. After 15 days, the patient's encephalopathy gradually improved. He was weaned off the ventilator and underwent intense physiotherapy. The patient was discharged from hospital one month after admission.

Exertional Heat Stroke-Induced Acute Liver Failure and Liver Transplantation

“…[12][13][14] In 1 case report, NAC was continued until day 29 when ALT was below 500 U/L. 13 The role of NAC in EHS-ALI/ALF remains unclear, but meta-analyses and trials have found that NAC is beneficial in nonacetaminophen ALF, especially in patients with early encephalopathy. 11,15,16 In the absence of larger studies confirming efficacy, giving NAC to patients with EHS-induced ALF early is likely prudent given the relative safety of the therapeutic.…”

A Case of Exertional Heat Stroke Complicated by Hypoxic Hepatitis

“…Successful treatments with emergency liver transplantation [6][7][8][9][10][11][12][13][14][15], MARS [16], plasma exchange alone [17,18], and hemofiltration [19] as well as cold dialysis and hemofiltration [20] have been published. ere is growing evidence that conservative management seems to be sufficient for the management of most cases, and a delayed transplant strategy is reasonable [8,12,[21][22][23][24][25][26][27][28][29][30][31], with cases reporting successful transplant after delaying transplantation in favour of spontaneous recovery [8,12]. Most reported cases survived, but fatalities have been reported due to liver failure [8,[32][33][34] or transplant complications [35][36][37].…”

“…Nevertheless, early induction of cooling treatment, ideally reaching <38.9°C within 30 minutes, seems to be paramount [20,38,39]. Also, the administration of N-acetyl-cysteine was shown to improve transplant-free survival [40,41] and has been reported in acute liver failure secondary to heat stroke [8,21,22]. It could also be shown that hypophosphatemia <0.5 mmol/l at admission, as was present in our patient, could predict the occurrence of acute liver failure [42], although it is unclear whether there is a causative connection.…”

Liver Transplantation for Treatment of Acute Liver Failure Due to Heat Stroke

“…Exertional heat stroke occurs in younger individuals, usually with no previous medical records, and is associated with vigorous activities under extreme temperature, such as longdistance running or military maneuvers, just as it happened in our patient. It has been also described in conditions of high ambient temperature while working or even in a dry air hot sauna cabin [1,2,[5][6][7][8][9][10][11]. Potential complications after heat stroke include acute renal failure, disseminated intravascular coagulation, rhabdomyolysis, acute respiratory distress syndrome, and hepatic failure, not uncommonly followed by death.…”