Bowel Ischemia in Heat Stroke: A Rare Complication

Abstract

Introduction: Exertional Heat Stroke (EHS) is one of the leading causes of death in young athletes. This is commonly seen in youngsters who engage in heavy exercise during periods of high ambient temperature. We report a case of a young female who developed bowel ischemia and shock liver after a marathon run on a warm summer afternoon. Case: A 27 y/o female was brought to the ER after she collapsed an hour into a marathon. At presentation she was hyperthermic with T of 40.2 °C, encephalopathic and hypotensive. She was rapidly cooled with IV cold normal saline and cooling blankets. Initial evaluation showed evidence of SIRS, lactic acidosis and rhabdomyolysis with acute kidney injury. Her mental status improved within a few hours of cooling and resuscitation. By the next day she developed bloody diarrhea and labs showed acute liver failure with elevated transaminases (ALT: 1484 AST:1217), and elevated PT & PTT, along with worsening of rhabdomyolysis with further elevation of creatine kinases (CK: 2213, CK-MB: 47.38). This was complicated by development of Disseminated Intravascular Coagulation (DIC) with acute thrombocytopenia, elevated D-Dimer and reduced Fibrinogen, and hemolysis. Gastroenterology and Hematology concluded that this was bowel ischemia, shock liver and DIC from Heat stroke. She was managed with aggressive IV fluid resuscitation and her symptoms resolved over the next two days. Following up in clinic two weeks after discharge, she was asymptomatic and her labs showed return of liver function, renal function and hemogram to baseline. Discussion: Exertional Heat illness is a continuum of illnesses arising from the body's inability to cope with heat during exertion, which range from heat cramps to life threatening Exertional Heat Stroke (EHS). Athletes performing intense exercise in high ambient temperature and humidity are at risk for EHS. Despite increased awareness in athletes and coaches, deaths related to EHS appear to be on the rise. EHS is a multisystem, life-threatening syndrome characterized by CNS dysfunction and end organ damage with high body temperatures. The complications of EHS are as a direct result of ischemia and oxidative & nitrosative stress which commonly include kidney injury, liver injury or rhabdomyolysis and CNS dysfunction (which ranges from disorientation and headache to seizure and coma). DIC has been reported in some severe cases but Intestinal complications are rare in EHS. Our patient had a global hypoperfusion state from EHS resulting in bowel ischemia that manifested as intestinal bleeding. Literature reveals one case where EHS lead to Colon perforation from bowel ischemia due to lack of timely intervention. Early recognition and timely management of EHS is crucial to prevent serious complications like bowel ischemia and colon perforation.