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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 2  |  Issue : 1  |  Page : 29-31

Heatstroke with rhabdomyolysis resulting in ischemic brain stroke and myocardial infarction


Department of GIM, Hamad General Hospital, Doha, Qatar

Date of Web Publication27-Mar-2018

Correspondence Address:
Dr. Ijaz Kamal
Department of GIM, Hamad General Hospital, Doha
Qatar
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/LJMS.LJMS_1_18

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  Abstract 


We report a case of heatstroke with rhabdomyolysis and myoglobinuria, which was complicated by cerebrovascular accident and myocardial infarction. Heatstroke can cause multiple serious systemic complications ranging from rhabdomyolysis to disseminated intravascular coagulation with multi-organ failure. However, it is also critical to consider its potential deleterious effects on the central nervous and cardiovascular systems. The complications of heatstroke can be explained by the combination of hypoperfusion and other mechanisms causing increased inflammatory response and thrombosis.

Keywords: Central nervous system, cerebrovascular accident, disseminated intravascular coagulation, myocardial infarction, stroke


How to cite this article:
Kamal I, Athreya A, Elzouki AN. Heatstroke with rhabdomyolysis resulting in ischemic brain stroke and myocardial infarction. Libyan J Med Sci 2018;2:29-31

How to cite this URL:
Kamal I, Athreya A, Elzouki AN. Heatstroke with rhabdomyolysis resulting in ischemic brain stroke and myocardial infarction. Libyan J Med Sci [serial online] 2018 [cited 2018 May 23];2:29-31. Available from: http://www.ljmsonline.com/text.asp?2018/2/1/29/228673




  Introduction Top


Heatstroke is a serious medical illness due to elevated core body temperature more than 40°C and is associated with central nervous dysfunction, delirium, or coma.[1],[2],[3] Heatstroke results from thermoregulatory failure and exacerbated acute phase response, causing damage to the central nervous system (CNS) and other organs.[2],[3] It is associated with mortality as high as 10%–50%.[2] Those who survive may sustain permanent neurologic dysfunction.[2],[3] Herein, we report a case of heatstroke presenting with encephalopathy and rhabdomyolysis which was complicated by ischemic stroke and myocardial infarction (MI).


  Case Report Top


A 46-year-old Caucasian male was admitted to the hospital for collapse and confusion during work on a hot summer day. The average temperature was 47°C on that day. The patient fell to the ground after he felt dizzy. The history was taken from his friends.

He came to Qatar 2 months ago to work as a construction laborer. He is a smoker and smokes 10 cigarettes/day for the last 20 years. He used to drink alcohol socially but quitted before coming to Qatar. He was not on any medication. He has no known allergies.

Initial resuscitation was done in ambulance and in the emergency department including intravenous fluid and cooling with wet towels. His initial body temperature was 40.5°C (105°F) as per his medical records.

On admission to a medical unit, he was confused and disoriented in time and space. He was aphasic. His facial and limited cranial nerve examination was normal. He was moving all the limbs. The rest of his neurological examination was difficult to perform as he was confused. He was euthermic with 36.5°C (97.8°F). His heart rate was 96/min and regular, and his blood pressure was 100/70 mmHg. His chest, cardiovascular, and abdominal examination was unremarkable.

His initial computed tomography brain was normal. His laboratory test results showed raised white blood cell count of 15/UL, hemoglobin of 15.4 g/dL, elevated creatinine of 248 umol/L, and elevated calcium of 2.64 mmol/L. His creatine phosphokinase was elevated 9000 IU/L while urine dipstick was positive for myoglobinuria. Microscopic evaluation of the urine shows red blood cells <4 which confirmed myoglobinuria due the rhabdomyolysis. His liver function, toxicology screen, and coagulation profile were normal.

He was admitted as a case of heatstroke complicated by acute kidney injury, rhabdomyolysis, and myoglobinuria.

His electrocardiography showed T-waves changes in lateral leads and his serial cardiac enzymes showed a rising trend (troponin I from 0.253 to 14.11). On the 2nd day of admission, he became alert and responsive after initial management with intravenous fluids, but he was unable to speak. His comprehension and naming ability were very poor. Global aphasia due to cerebrovascular accident (CVA) was considered and, therefore, magnetic resonance imaging (MRI) brain was arranged.

MRI brain showed a recent left-sided middle cerebral artery (MCA) territory infarction [Figure 1] right frontal-parietal small recent watershed infarction [Figure 2]. This study confirmed that our patient who was admitted as a case of heatstroke with rhabdomyolysis was complicated by ischemic brain stroke and MI.
Figure 1: Axial T2-weighted image, fluid-attenuated inversion recovery: Corresponding areas of high-signal intensity in T2 and fluid-attenuated inversion recovery with some effacement of frontal horn of the left lateral ventricle, suggestive of acute left middle cerebral artery territory infarction

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Figure 2: Axial diffusion-weighted magnetic resonance imaging: Multiple areas of restricted diffusion in the frontal and parietal cortical and subcortical regions bilaterally, suggestive of recent watershed infarctions

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Over the period of his stay in the hospital, he gradually recovered from the acute kidney injury and was managed conservatively for the MI and brain stroke. He was reviewed by stroke team as well as by physiotherapist, occupational and speech therapist. He required nasogastric tube initially for feeding because of high risk of aspiration. He was transferred to the rehabilitation unit with inpatient speech therapy. A follow-up was organized with cardiologist for further evaluation of coronary artery disease.


  Discussion Top


Heatstroke is a condition which is associated with hot dry skin, dehydration, and CNS abnormalities including delirium, convulsion, or coma, when the core body temperature rises above 40°C.[2],[3] Our case report is a typical example of heatstroke which is common due to working in the hot climate like Qatar. His presentation with encephalopathy with impaired consciousness is similar to other case reports. [4, 5, 6] However, the diagnosis of CVA and MI is rare in medical literature. Commonly reported conditions are ataxia and difficulty with balance and coordination. [7,8] MRI brain findings of hyperintense signals have been reported before; [8,9] however, our case shows sign of MCA infarction and watershed infarction which can be explained by the pathophysiology of heatstroke.

The pathogenesis of heatstroke is multifactorial and attributable to the multiple mechanisms which can cause the CNS injury and multi-organ failure. Usually, it is the combination of failure of thermoregulation system and exacerbated acute phase response. The multi-organ damage is usually due to circulatory failure, direct cytotoxic effect of heat, and exaggerated response of acute phase reaction causing the release of inflammatory cytokines and endotoxin. This process can lead to endothelial cell injury which increases the adhesiveness, proliferation, and diffuse microvascular thrombosis.[10] This whole process is like the process of sepsis,[11],[12],[13] which can lead to disseminated intravascular coagulation. During the heat stress, the blood is shunted away from main organs and redirected to periphery to dissipate the heat.[3] Visceral perfusion is reduced particularly in intestine and kidney which can cause acute kidney injury and diarrhea. The circulatory collapse with hypovolemia resulting in hyperviscosity and increased thrombosis can cause the brain stroke and MI.[7]

The other possible mechanism for MI is the tachycardia and increased cardiac output due to elevated body temperature.[7]

Finally, there is a direct toxic effect of heat on neuron particularly of the cerebellar Purkinje cells causing the long-term problem with coordination and balance.[6]

In short, the mechanism behind the brain stroke and MI are circulatory failure, increased inflammatory response, and diffuse microvascular thrombosis and small vessel disease.[9],[10]


  Conclusion Top


Heatstroke is a serious medical emergency resulting from high body temperature. The main cause is the thermoregulatory failure, hypovolemia, and excessive production of inflammatory cytokines, resulting in a cascade of reactions causing endothelial cell damage thrombosis and sepsis-like picture. Our case report is the example of heatstroke complicated by brain stroke and MI not reported before. Heatstroke should be in the differential diagnosis of patients presenting with encephalopathy. The incidence of heatstroke can be reduced by the preventative measures such as increasing the awareness and adaptation of protective measures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Guerrero WR, Varghese S, Savitz S, Wu TC. Heat stress presenting with encephalopathy and MRI findings of diffuse cerebral injury and hemorrhage. BMC Neurol 2013;13:63.  Back to cited text no. 1
[PUBMED]    
2.
Bouchama A. Heatstroke: A new look at an ancient disease. Intensive Care Med 1995;21:623-5.  Back to cited text no. 2
    
3.
Bouchama A, Knochel JP. Heat stroke. N Engl J Med 2002;346:1978-88.  Back to cited text no. 3
    
4.
Kalita J, Misra UK. Neurophysiological studies in a patient with heat stroke. J Neurol 2001;248:993-5.  Back to cited text no. 4
    
5.
Ookura R, Shiro Y, Takai T, Okamoto M, Ogata M. Diffusion-weighted magnetic resonance imaging of a severe heat stroke patient complicated with severe cerebellar ataxia. Intern Med 2009;48:1105-8.  Back to cited text no. 5
    
6.
Yaqub B, Al Deeb S. Heat strokes: Aetiopathogenesis, neurological characteristics, treatment and outcome. J Neurol Sci 1998;156:144-51.  Back to cited text no. 6
    
7.
Lin MT. Heatstroke-induced cerebral ischemia and neuronal damage. Involvement of cytokines and monoamines. Ann N Y Acad Sci 1997;813:572-80.  Back to cited text no. 7
    
8.
Albukrek D, Bakon M, Moran DS, Faibel M, Epstein Y. Heat-stroke-induced cerebellar atrophy: Clinical course, CT and MRI findings. Neuroradiology 1997;39:195-7.  Back to cited text no. 8
    
9.
Adams HP Jr. del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, et al. Guidelines for the early management of adults with ischemic stroke: A guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the atherosclerotic peripheral vascular disease and quality of care outcomes in research interdisciplinary working groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007;38:1655-711.  Back to cited text no. 9
    
10.
Cannon JG. Inflammatory cytokines in nonpathological states. News Physiol Sci 2000;15:298-303.  Back to cited text no. 10
    
11.
Kurahashi K, Kajikawa O, Sawa T, Ohara M, Gropper MA, Frank DW, et al. Pathogenesis of septic shock in Pseudomonas aeruginosa pneumonia. J Clin Invest 1999;104:743-50.  Back to cited text no. 11
    
12.
Hallenbeck JM, Dutka AJ, Kochanek PM, Siren A, Pezeshkpour GH, Feuerstein G, et al. Stroke risk factors prepare rat brainstem tissues for modified local Shwartzman reaction. Stroke 1988;19:863-9.  Back to cited text no. 12
    
13.
Szold O, Reider-Groswasser II, Ben Abraham R, Aviram G, Segev Y, Biderman P, et al. Gray-white matter discrimination-a possible marker for brain damage in heat stroke? Eur J Radiol 2002;43:1-5.  Back to cited text no. 13
    


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