Abstract Exertional heat stroke (EHS) can occur following strenuous activity and is characterized by impaired thermoregulation causing hyperthermia, central nervous system dysfunction, and organ damage. We present two cases of EHS resulting in Acute Liver Failure (ALF), an uncommon complication of EHS. A healthy 26-year-old male presented to an outside hospital with encephalopathy and a maximum temperature of 39.5 °C after running a road race in a 98 °F heat index. He received on-scene immersive cooling. Admission labs showed creatinine 1.8 and lactate 6.6. He was volume resuscitated but deteriorated and was transferred to our tertiary medical center. Labs on transfer were notable for aspartate aminotransferase (AST) 6000, alanine transaminase (ALT) 3300, ammonia 490, international normalized ratio (INR) 14.6, platelets 18, fibrinogen60, D-dimer 20, creatinine 4.73, potassium 6.2, lactate 9.6, creatinine kinase (CK) 1660. He required renal replacement therapy (RRT) and intubation for respiratory failure. Computed tomography (CT) abdomen showed ischemic colitis. CT head demonstrated cerebral edema, and 3% hypertonic saline was administered. Magnetic Resonance Imaging (MRI) demonstrated a 0.8 cm hemorrhage in the right subcortical parietal lobe. He was emergently listed for orthotopic liver transplant (OLT) and was transplanted within 24 hours of presentation. He went on to fully recover with residual unilateral weakness attributed to his stroke. On the same day in the same geographic area, a 23-year-old male with history of depression and substance use disorder presented to an outside hospital with a maximum temperature of 39.2 °C and encephalopathy following strenuous exertion after an altercation with law enforcement. Admission laboratory studies demonstrated AST 3115, ALT 3300, ammonia 49, INR 2.1, platelets 109, fibrinogen 90, D-dimer20, creatinine 2.29, potassium 6.6, lactate 20, CK 5000. His urine toxicology was positive for amphetamines. He developed complications of severe coagulopathy, renal failure requiring RRT, ischemic colitis, and respiratory failure requiring intubation. He was transferred to our hospital for OLT evaluation 10 hours after presentation. After multi-disciplinary evaluation he was not listed for liver transplantation due to prior drug use and history of noncompliance with psychiatric therapies for depression. Patient died on hospital day 11. EHS resulting in ALF is rare. Treatment involves supportive care, and OLT is rarely indicated. These two cases highlight the severity of EHS and the rare need for rapid liver transplant evaluation. Due to encephalopathy associated with ALF, psychosocial evaluations for transplant candidacy were challenging and likely impacted the ability to safely list the second patient. This abstract is funded by: None
Spritzer et al. (Fri,) studied this question.