S2886 Exertional Heat Stroke-Induced Acute Liver Failure and Liver Transplantation: A Case Report

Abstract

Introduction: Exertional heat stroke (EHS) is characterized by excessive heat production and inadequate heat dissipation usually following heavy exertion in hot and humid climates. This is a medical emergency associated with hyperthermia and multiorgan dysfunction, including acute liver failure (ALF). Currently, there are no clear guidelines regarding the timing of liver transplantation (LT) in this patient population. Case Description/Methods: A 44-year old marathon runner with no past medical history presented to an outside hospital after being found unconscious following a 5-mile run in summer weather. Vitals were 39.4°C, HR 103, and MAP 50s. He was intubated, fluid resuscitated, started on vasopressors and broad-spectrum antibiotics, and admitted to a local intensive care unit where he underwent external cooling. Labs were notable for acute liver and kidney injury and rhabdomyolysis (peak ALT 10,850 IU/L, AST 870 IU/L, Cr 5.6 mg/dL and CK 16K U/L), and he required renal replacement therapy (Figure 1). He then developed disseminated intravascular coagulopathy (peak INR 7.9), which persisted despite multiple transfusions. Hepatitis panel was negative. He received N-acetylcysteine. On day 3, he was transferred to our hospital for consideration of LT. He was alert and interactive even while intubated. He was extubated, but after 48 hours became progressively encephalopathic. Therefore, he was listed for transplant as Status 1 and underwent successful cadaveric LT on day 7. Liver explant showed massive hepatocyte necrosis (>80%) in zones 2 and 3 and portions of zone 1. The patient was discharged on day 32 with recovery of renal function and at baseline mental status. His hospitalization was complicated by the development of an intra-abdominal hematoma and deep venous thrombosis. Two years post-LT, he continues to exhibit good graft function. Discussion: The overall mortality in EHS-related liver injury or failure has been shown to be 4-5%, and the liver transplantation rate ranges from 12.5-33.3%, with median time to liver transplantation of 3 days. A high index of suspicion and careful monitoring of mental status and coagulopathy are warranted given the high mortality rate in this patient population. In this patient, the decision to perform liver transplant was made after the development of hepatic encephalopathy and continued coagulopathy despite maximal medical therapy. This case illustrates the importance of early liver transplantation referral in patients with EHS-induced ALF.Figure 1.: Trend of patient's AST, ALT and total bilirubin during hospitalization.