Liver Failure Occurring As a Component of Exertional Heatstroke

Abstract

An unusual case of an exertional heatstroke in a healthy 25-year-old man is presented. Initially, the patient was deeply comatose and developed severe rhabdomyolysis and massive hepatic necrosis. Subsequently, he received a liver transplant with remarkable improvement in his mental status, although the rhabdomyolysis continued. The patient died 41 days after the transplant due to a complicating infection. Providing that infections can be effectively controlled, liver transplants might be a promising therapeutic alternative for the few patients who survive the initial neurological consequences of this unusual event.A n outbreak of heatstroke occurred among 50 police trainees who were participating in an intense recruitment training program in Massachusetts in 1988. Each experienced a variable degree of exercise-induced rhabdomyolysis. Forty of the trainees (80%) reported dark urine, 26 (52%) experienced myoglobinuria and hemoglobinemia, and 13 (26%) experienced kidney damage secondary to rhabdomyolysis. One recruit experienced hepatic failure and went into deep coma. This individual and his clinical course is the topic ofthis report. Case ReportA previously healthy 25-year-old white man without a history of alcohol or drug use, who had been on a diet to lose weight and who had been exercising vigorously for several hours in a deconditioned state, suddenly collapsed during supervised exercise. He was admitted to a local hospital in Massachusetts, unconscious, unresponsive to deep pain, hypotensive (70/0), hyperthermic (105°F rectal), tachypneic (60/minJ, and with tachycardia (12B/min).He experienced seizures which were treated with diazepam and phenytoin. Thereafter, he rapidly developed multisystem organ failure manifested as disseminated intravascular coagulation (DIC), liver and renal failure, and rhabdomyolysis. Because of combined renal and hepatic failure, he was transferred to the Presbyterian University Hospital in Pittsburgh on his sixth day after heatstroke for possible liver and kidney transplantation. On admission to the intensive care unit in Pittsburgh, he was comatose (grimaced to pain), had a rectal temperature of 3B.6°C, blood pressure of 110/70, heart rate of 124, and respiratory rate of 22. His pupils were minimally reactive; gag and corneal reflexes were present but reduced; and his neck was supple. His limbs were flaccid with reduced muscle tone; deep tendon reflexes were present. His sclera were icteric. His abdomen was distended slightly but without organomegaly and ascites. Bowel sounds were reduced. Rectal examination revealed stool that was guaiac-positive. The rest of his examination was unremarkable. He was anuric (50 mL/day). The little urine that was collected contained 100-300 red blood cells per high-power field, 0-2 white blood cells per high-power field, and was myoglobin-positive. The other laboratory data obtained on admission are shown in Table 1. A hepatitis profile for hepatitis B virus and delta virus were negative whereas the hepatitis A virus screen was positive for immun...

Pathophysiology of Heat Stroke

“…This is demonstrated by an amateur long-distance runner that was hospitalized for 10 days after collapsing from exertional heat stroke during a 6-mile foot race. Physicians may attempt to treat recurrent hyperthermia episodes with NSAIDs, but these drugs are toxic to the liver and have been associated with the need for transplantation of this organ [129,156,157,340,406]. Rapid cooling and aspirin therapy were ineffective in reducing body temperature and the patient died [265].…”

“…Therefore, lung and/or liver dysfunction may cause an increase in circulating endotoxin concentrations in heat stroke patients [60,286]. Liver dysfunction may be treated with transplantation or patients may show complete biochemical and histologic recovery without this procedure [38,40,60,156,157,286,340,371,372]. Proper interpretation of prognostic criteria is crucial before considering a patient for liver transplantation since the benefits of this procedure remain controversial [143].…”

“…Proper interpretation of prognostic criteria is crucial before considering a patient for liver transplantation since the benefits of this procedure remain controversial [143]. Acetaminophen (e.g., Tylenol) has been associated with liver failure and a need for liver transplantation, which is commensurate with the known toxic effects of NSAIDs on this organ [129,156,157,340,406].…”

Anstrengungs-induzierter Hitzschlag

“…Allerdings existieren in der Literatur nur drei Fälle einer Lebertransplantation bei Hitzschlag, wobei keiner der Patienten länger als 11 Monate überlebte [3,15,28]. Allerdings existieren in der Literatur nur drei Fälle einer Lebertransplantation bei Hitzschlag, wobei keiner der Patienten länger als 11 Monate überlebte [3,15,28].…”

Living donor liver transplantation with noninvasive ventilation for exertional heat stroke and severe rhabdomyolysis

“…Mild to moderate hepatic injury is a common feature of EHS,3 but some patients experience fatal extensive hepatocellular damage 4–6. In EHS patients with severe hepatocellular damage, supportive therapy alone has proven ineffective and liver transplantation has been advocated for these patients 6–8. However, three patients with EHS who underwent liver transplantation died within one year 6–8…”