Analysis of clinical characteristics and risk factors of early heat stroke-related acute liver injury / 中华危重病急救医学

OBJECTIVE@#To analyze the clinical characteristics and risk factors of early acute liver injury in patients with heat stroke (HS), and to provide basis for early identification of HS-related liver injury and its pathogenesis in clinical practice.@*METHODS@#The clinical data of patients with HS admitted to the department of critical care medicine of Haian People's Hospital from June 2015 to August 2022 were retrospectively analyzed. The patients with HS were divided into early liver injury group and early non-liver injury group according to the occurrence of acute liver injury within 24 hours of admission. The differences of basic data, clinical data, laboratory indexes and clinical outcomes of the two groups were analyzed. Logistic regression was used to analyze the risk factors for early HS-related acute liver injury, and receiver operator characteristic (ROC) curves were drawn to evaluate their value in predicting the occurrence of early HS-related acute liver injury.@*RESULTS@#A total of 76 patients with HS were enrolled, and 46 patients with acute liver injury, accounting for 60.53%. In the early liver injury group, 14 patients (30.43%) had elevated aminotransferase alone, 9 patients (19.57%) had elevated total bilirubin (TBil) alone, and 23 patients (50.00%) had elevated both aminotransferase and TBil. Among the patients with elevated aminotransferases, 24 patients (64.87%) had mild elevation, 5 patients (13.51%) had moderate elevation, 8 patients (21.62%) had severe elevation. Compared with the early non-liver injury group, acute physiology and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), arterial blood lactate (Lac), interleukin-6 (IL-6), procalcitonin (PCT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), TBil, γ-gamma glutamyl transferase (γ-GGT), lactate dehydrogenase (LDH), creatine kinase (CK), MB isoenzyme of creatine kinase (CK-MB), cardiac troponin I (cTnI), myoglobin (MYO), N-terminal B-type pro-brain natriuretic peptide (NT-proBNP), prothrombin time (PT), activated partial thromboplastin time (APTT), D-dimer in the early liver injury group were significantly increased, while platelet count (PLT) were significantly decreased within 24 hours after admission, the 28-day mortality was significantly increased [28.26% (13/46) vs. 6.67% (2/30)], and the differences were statistically significant (all P < 0.05). Univariate Logistic regression analysis showed that APACHE II score, SOFA score, PLT, Lac, IL-6, PCT, γ-GGT, LDH, CK, CK-MB, cTnI, MYO, PT, APTT, D-dimer were risk factors of early HS-related acute liver injury (all P < 0.05). Multivariate Logistic regression analysis showed that PLT, IL-6, and LDH were independent risk factors of early HS-related acute liver injury [odds ratio (OR) and 95% confidence interval (95%CI) were 0.986 (0.974-0.998), 1.027 (1.012-1.041), and 1.002 (1.000-1.004), all P < 0.05]. The ROC curve analysis showed that the area under the ROC curve (AUC) of PLT, IL-6 and LDH for predicting the occurrence of early HS-related acute liver injury was 0.672 (95%CI was 0.548-0.797), 0.897 (95%CI was 0.824-0.971) and 0.833 (95%CI was 0.739-0.927), respectively. IL-6 had the highest predictive value for early HS-related liver injury. When the optimal diagnostic threshold of IL-6 was 48.25 ng/L, the sensitivity was 95.7%, the specificity was 73.3%, and the predictive value of PLT was the lowest.@*CONCLUSIONS@#The early HS-related liver injury is mainly manifested as the simultaneous elevation of aminotransferase and TBil, and most of cases are mild liver injury. PLT, IL-6 and LDH are independent risk factors of early HS-related acute liver injury.

Heat stroke during long-term clozapine treatment: should we be concerned about hot weather? / Heat stroke durante tratamento de longo prazo com clozapina: devemos nos preocupar com o tempo quente?

Objective To describe the case of a patient with schizophrenia on clozapine treatment who had an episode of heat stroke. Case description During a heat wave in January and February 2014, a patient with schizophrenia who was on treatment with clozapine was initially referred for differential diagnose between systemic infection and neuroleptic malignant syndrome, but was finally diagnosed with heat stroke and treated with control of body temperature and hydration. Comments This report aims to alert clinicians take this condition into consideration among other differential diagnoses, especially nowadays with the rise in global temperatures, and to highlight the need for accurate diagnosis of clinical events during pharmacological intervention, in order to improve treatment decisions and outcomes.

Objetivo Descrever o caso de um paciente com esquizofrenia em tratamento com clozapina acometido por um episódio de heat stroke. Descrição do caso Durante uma onda de calor em janeiro e fevereiro de 2014, um paciente com esquizofrenia em tratamento com clozapina foi inicialmente encaminhado para diagnóstico diferencial de infecção sistêmica e síndrome neuroléptica maligna, tendo obtido o diagnóstico final de heat stroke, tratado com controle de temperatura corporal e hidratação. Comentários Este relato de caso tem como objetivo alertar os clínicos para este diagnóstico diferencial, que pode surgir com mais frequência à medida que as temperaturas globais continuarem a aumentar, e também destacar a importância da realização de um diagnóstico mais acurado, que possa melhorar as decisões de tratamento e os desfechos clínicos para os pacientes.

Golpe de calor: a propósito de un caso clínico / Heat stroke. a case report

El golpe de calor es una entidad poco frecuente y subdiagnosticada. La elevación de la temperatura corporal es la que desencadena las disfunciones metabólicas que pueden incluso llevar a la muerte. Se presenta el caso de un militar que se encontraba realizando ejercicios de infantería, durante el mes de septiembre, en días donde se produjeron condiciones climáticas extremas y desarrolla un cuadro de Disfunción Orgánica Múltiple (DOM) primaria; fue llevado al Servicio de Emergencia del Hospital de Fray Bentos, Río Negro. La evolución inicial se caracterizó por deterioro de la función neurológica, respiratoria, necesidad de ventilación mecánica, falla renal aguda y disfunción hematológica; se establecieron los diagnósticos de golpe de calor, injuria renal, rabomiólisis, insuficiencia respiratoria aguda y coagulación intravascular diseminada (CID). A pesar del tratamiento y manejo de sostén tiene una mala evolución, falleciendo a las 48 horas del ingreso. El caso nos recuerda que la exposición a condiciones de calor por arriba de la temperatura corporal, deteriora los mecanismos de control de calor corporal y metabólico. Es necesario un diagnóstico rápido y un manejo de sostén para conseguir una evolución satisfactoria.

A heat stroke is a very rare and under diagnosed entity. The rise in the body’s temperature is the element that triggers the metabolic dysfunctions that can even lead to death. A case of a soldier is presented; this soldier was training, doing his infantry exercises routine, during September, in days were extreme climate situations were happening, installing a case of primary Multiple Organ Dysfunction (MOD) syndrome. The soldier was taken to the Emergency Service in Fray Bentos’ Hospital, in Rio Negro. The initial evolution was clumsy and slowly, and the neurologic and breathing functions were worsening, with acute renal failure, and also hematological dysfunction. In addition to this, the patient was in need of mechanic ventilation. The diagnosis of temperature shock, acute renal injury, Rhabdomyolysis, acute respiratory failure and disseminated intravascular coagulation (DIC) were established. Supportive care was given to the patient, with an un satisfactory development, leading to death 48 hours after the hospital admission. This case reminds us that, the exposure to weather conditions that are over the body temperature interferes in the metabolism and the body’s mechanisms for controlling heat. A quick diagnosis and supportive care are needed in order to achieve a satisfactory evolution.

Effects of propofol on damage of rat intestinal epithelial cells induced by heat stress and lipopolysaccharides

Gut-derived endotoxin and pathogenic bacteria have been proposed as important causative factors of morbidity and death during heat stroke. However, it is still unclear what kind of damage is induced by heat stress. In this study, the rat intestinal epithelial cell line (IEC-6) was treated with heat stress or a combination of heat stress and lipopolysaccharide (LPS). In addition, propofol, which plays an important role in anti-inflammation and organ protection, was applied to study its effects on cellular viability and apoptosis. Heat stress, LPS, or heat stress combined with LPS stimulation can all cause intestinal epithelial cell damage, including early apoptosis and subsequent necrosis. However, propofol can alleviate injuries caused by heat stress, LPS, or the combination of heat stress and LPS. Interestingly, propofol can only mitigate LPS-induced intestinal epithelial cell apoptosis, and has no protective role in heat-stress-induced apoptosis. This study developed a model that can mimic the intestinal heat stress environment. It demonstrates the effects on intestinal epithelial cell damage, and indicated that propofol could be used as a therapeutic drug for the treatment of heat-stress-induced intestinal injuries.

Insuficiência hepática fulminante por intermação induzida por exercício / Fulminant hepatic failure (FHF) by exercise-induced exertional heatstroke

Intermação induzida por exercício é uma condição potencialmente fatal causada pela elevação extrema da temperatura corporal central. Envolvimento hepático leve a moderado afeta todos os pacientes e manifesta-se pela elevação das enzimas hepáticas. A ocorrência de falência hepática no curso da intermação por exercício é rara e tem prognóstico reservado. Relata-se um caso de insuficiência hepática fulminante em um homem de 36 anos após correr 8km em corrida de rua (corrida rústica) na cidade de Manaus (AM). O paciente desenvolveu insuficiência renal aguda, rabdomiólise e achados compatíveis com insuficiência hepática fulminante (elevação importante das aminotransferases, coagulopatia, letargia e episódios de confusão). As funções hepáticas e renais apresentaram melhora gradual e espontânea sem necessidade de diálise. Três meses após o paciente encontrava-se bem, com enzimas hepáticas normais e com retorno gradual à prática de esportes. Embora rara, a falência hepática aguda deve ser incluída nas complicações da intermação induzida por exercício, a qual pode ter resolução espontânea com medidas conservadoras.

Exercise-induced exertional heatstroke (EHS) is a potentially fatal disorder caused by extreme elevation of the core body temperature. Mild to moderate liver involvement affects nearly all patients and it is manifested by increase of the serum liver enzymes. Liver failure occurring as a component of exertional heatstroke is rare and carries a poor prognosis. A case of acute liver failure in a healthy 36 year-old man after participation in an 8-km race in Manaus, located near the Amazon Tropical Forest in Brazil, is reported here. The patient presented renal failure, severe rhabdomyolysis and findings of fulminant hepatic failure (very high aminotransferases levels, elevated international normalized ratio (INR), lethargy and episodes of confusion). Hepatic and renal functions improved spontaneously with conservative measures and he was discharged within eight days. Three months later he was completely asymptomatic and gradually running again. Although rare, acute liver failure should be included in the complications associated with exertional heatstroke. Conservative management may be effective in some patients with this kind of acute liver failure.

A Case of Multiple Organ Failure due to Heat Stoke Following a Warm Bath

Heat stroke is a potentially fatal disorder that's caused by an extreme elevation in body temperature. We report here an unusual case of multiple organ failure that was caused by classical, nonexertional heat stroke due to taking a warm bath at home. A 68 year old diabetic man was hospitalized for loss of consciousness. He was presumed to have been in a warm bath for 3 hrs and his body temperature was 41 degrees C. Despite cooling and supportive care, he developed acute renal failure, disseminated intravascular coagulation (DIC) and fulminant liver failure. Continuous venovenous hemofiltration was started on day 3 because of the progressive oligouria and severe metabolic acidosis. On day 15, septic ascites was developed and Acinetobacter baumanii and Enterococcus faecium were isolated on the blood cultures. In spite of the best supportive care, the hepatic failure and DIC combined with septic peritonitis progressed; the patient succumbed on day 25.