Heat stroke with bimodal rhabdomyolysis: a case report and review of the literature

Abstract

BackgroundSevere heat stroke tends to be complicated with rhabdomyolysis, especially in patients with exertional heat stroke. Rhabdomyolysis usually occurs in the acute phase of heat stroke. We herein report a case of heat stroke in a patient who experienced bimodal rhabdomyolysis in the acute and recovery phases.Case presentationA 34-year-old male patient was found lying unconscious on the road after participating in a half marathon in the spring. It was a sunny day with a maximum temperature of 24.2 °C. His medical and family history was unremarkable. Upon arrival, his Glasgow Coma Scale score was 10. However, the patient’s marked restlessness and confusion returned. A sedative was administered and tracheal intubation was performed. On the second day of hospitalization, a blood analysis was compatible with a diagnosis of acute hepatic failure; thus, he received fresh frozen plasma and a platelet transfusion was performed, following plasma exchange and continuous hemodiafiltration. The patient’s creatinine phosphokinesis (CPK) level increased to 8832 IU/L on the fifth day of hospitalization and then showed a tendency to transiently decrease. The patient was extubated on the eighth day of hospitalization after the improvement of his laboratory data. From the ninth day of hospitalization, gradual rehabilitation was initiated. However, he felt pain in both legs and his CPK level increased again. Despite the cessation of all drugs and rehabilitation, his CPK level increased to 105,945 IU/L on the 15th day of hospitalization. Fortunately, his CPK level decreased with a fluid infusion. The patient’s rehabilitation was restarted after his CPK level fell to <10,000 IU/L. On the 31st day of hospitalization, his CK level decreased to 623 IU/L and he was discharged on foot. Later, a genetic analysis revealed that he had a thermolabile genetic phenotype of carnitine palmitoyltransferase II (CPT II).ConclusionsPhysicians should pay special attention to the stress of rehabilitation exercises, which may cause collapsed muscles that are injured by severe heat stroke to repeatedly flare up.

Thermal distribution, physiological effects and toxicities of extracorporeally induced whole‐body hyperthermia in a pig model

“…Although rhabdomyolysis is a known complication of heat stroke, in the literature of human eWBH, this complication is not described to the same extent as we found in our animal model (Yoshizawa et al, 2016). In humans receiving eWBH, Zwischenberger et al reported a CK rise up to 1846 ± 1823 U/L 2 hr after the procedure (normal value <170 U/L), Locker et al described grade 1 (National Cancer Institute Common Toxicity Criteria) CK rise in 33% and grade 2 in 25% of the patients (time interval of occurrence of CK rise not reported) and Zablow et al also reported mild CK level increases, spontaneously recovering after 2 weeks (only measured after 3 and 14 days) (Locker et al, 2011;Zablow et al, 1997;Zwischenberger et al, 2001).…”

The Fire from Within: Multiorgan Failure with Bimodal Rhabdomyolysis from Exertional Heat Stroke

“…is genetic variant may cause the bimodality of rhabdomyolysis during even the mildest of rehabilitation as seen in the Japanese population [9]. Accordingly, our patient has a Japanese lineage and if proven to have this genetic variant, it may have repercussions of him being an athlete in the future.…”

“…is was managed conservatively with hydration and rest from physical rehabilitation. A genetics consultation was done, and carnityl palmitoyltransferase II (CPT II) levels and phenotyping were requested (pending as of this writing) to determine genetic predisposition to rhabdomyolysis as evidenced by a bimodal rise in CPKs [9]. He was eventually discharged stable and ambulatory.…”

Chemically Activated Cooling Vest’s Effect on Cooling Rate Following Exercise-Induced Hyperthermia: A Randomized Counter-Balanced Crossover Study

“…This has been shown to maximize EHS patients’ survival [ 5 ] and minimize organ damage from prolonged heat stress [ 21 ]. In the case studies of patients who were cooled using cooling modalities with suboptimal cooling rates (<0.15 °C·min −1 ), it was reported that patients experienced sequela (e.g., rhabdomyolysis, ischemic bowel, bilateral compartment syndrome, acute kidney injury, acute liver failure, and disseminated intravascular coagulopathy) requiring hospitalization [ 21 , 22 , 23 , 24 ]. Therefore, selection of appropriate cooling methods can dictate the outcome of EHS treatment and clinicians should recognize limitations of cooling methods other than whole-body cold-water immersion (e.g., cooling vests, ice packs, intravenous infusion, and gastric lavage) as a modality of EHS treatment.…”