Life‐threatening heat‐related illness with severe hyponatremia in an aluminum smelter worker

Abstract

Heat stress is a recognized occupational hazard in aluminum smelter pot rooms. This is the report of an unusual and complex case of heat‐related illness in an aluminum smelter worker. The 34‐year‐old male US worker developed life‐threatening heat‐related illness in August 2018, on his first day back at work after a 7‐day absence. The worker initially presented with bilateral hand then all‐extremity cramping followed some hours later by a generalized seizure and acute mental status changes, including combativeness. Emergency room evaluation identified a serum sodium level of 114 mmol/L. Acute liver and kidney injury ensued along with profound rhabdomyolysis, with peak total creatinine phosphokinase level reaching over 125 000 units/L at 3 days post incident. Initial ventilatory support, careful fluid resuscitation, and electrolyte management were provided. Metabolic encephalopathy resolved. Complications included sepsis. After 5 days in the intensive care unit and eight additional days of inpatient management, observation, and the initiation of rehabilitation, the worker was discharged. Residual effects include polyneuropathy of upper and lower extremities and the postdischarge magnetic resonance imaging finding of a cerebellar lesion. Prevailing considerations in the differential diagnosis included exertional heat stroke and/or exertion‐associated hyponatremia with encephalopathy.

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“…For example, nonopioid medications such as serotonin-norepinephrine inhibitors have shown promise in the prevention and treatment of chronic pain, and their impact appears to be modified by the presence of depression: they are more effective in depressed patients. 42 While a majority of patients in this study had ongoing MSAP at week 6, a smaller but still sizeable proportion of participants had widespread pain. Predictors of widespread pain were different than persistent moderate to severe pain in this cohort, suggesting that the pathogenesis of widespread pain is different.…”

“…36,37 Occupational heatstroke was described in construction workers, 38,39 a baker, 40 gold miners, 41 and an aluminum smelter pot room process-control operator. 42 Environmental circumstances including heat waves 29,31,40,43,44 and sunbathing 45 were identified as risks, as was non-endemic heat due to a dry sauna exposure. 46 Exertional heat stress was described in runners, [47][48][49][50] individuals along the US-Mexico border, 28 participants in the Hajj pilgrimage to Mecca, 51 and military personnel.…”

“…One study found sodium >145 was an independent risk factor for death 44 ; in contrast, low sodium was reported to be common in other cases. 42,65 A case series found both high and low values of potassium, sodium, calcium, and phosphorus. 65 Aspartate aminotransferase >1000 units was associated with death.…”

“…30,36,38,48,49,[53][54][55][56][57]60,68,70,[80][81][82] Several patients required a prolonged hospitalization up to 75 days. 39,63,83 Notable case sequelae were ventricular tachycardia, 39 aspiration, 40,60 cerebral edema, 53 seizures, 38,55 residual neurological deficits, 42,59,63,66 acute liver failure that required transplantation 46,83,84 or supportive care, 45 and death. 27,29,31,34,43,47,59,65,66,68 It was noted that many patients arrived via EMS, yet cooling was often delayed.…”

Sustainable solutions to mitigate occupational heat strain – an umbrella review of physiological effects and global health perspectives

“…Therefore, with prolonged sweating, if only water losses are replaced without additional electrolyte consumption, issues may arise with maintaining appropriate blood sodium levels and hydration status [ 153 ]. Indeed, case reports of life-threatening hyponatremia due to occupational heat strain with insufficient sodium replacement have been documented [ 154 ]. It is therefore critical that during work that elicits heavy sweating, lasting for several hours, workers should ingest sport drinks containing balanced electrolytes, as is presently recommended [ 143 ] .…”