Unexpected extrapyramidal symptoms and pulmonary aspergillosis in exertional heatstroke with fulminant liver failure: a case report

Therapeutic Plasma Exchange in Severe Rhabdomyolysis: A Case-Control Study

INTRODUCTION

 Rhabdomyolysis is a serious condition that can cause acute kidney injury (AKI), compartment syndrome, severe metabolic and electrolyte derangement leading to arrhythmias, and even death. Total plasma exchange (TPE) has been used as a treatment modality to clear myoglobin, but the evidence is limited. In this study, we aim to investigate the use of TPE in critically ill rhabdomyolysis patients.

METHODS

 We retrospectively chart reviewed adult patients admitted to the intensive care unit (ICU) with a diagnosis of rhabdomyolysis between 2012 and 2021. We dichotomized patients into two groups based on whether TPE was used or not in addition to standard care. PRISMA machines with TPE2000 filters and either 5% albumin or fresh frozen plasma were used in the TPE group.

RESULTS

 The patients' age ranged from 23 years to 87 years (mean 49.4, SD 18.1), and 51% were male. Initial creatinine ranged from 0.6 to 16mg/dL (mean 3.4, SD 2.7), creatinine phosphokinase (CPK) from 403-93,232 U/L, and myoglobin from 934 to >20,000. The Sequential Organ Failure Assessment (SOFA)scores on admission ranged from 6 to 17 (mean 7.23, SD 3.40). Overall, 28.78% (N=19) of the patients received therapeutic plasma exchange. The overall mortality in our study was 31.9%, with the length of ICU stay ranging from 1-25 days (mean 7.10, SD 5.91) among survivors. Older age and the presence of shock were predictive of mortality in univariate and multivariate analyses. There was no statistically significant association in mortality between the TPE and non-TPE groups (36.84% in TPE vs. 36.17% in the non-TPE group, OR 0.7209, p=0.959). Only two patients in the non-TPE group developed CKD/ESRD on long-term follow-up.

CONCLUSION

Our study showed that TPE administration in critically ill patients with rhabdomyolysis did not improve mortality or length of ICU stay. Further studies are required to elucidate its indication and effect on long-term renal outcomes.

A Case of Exertional Heat Stroke Complicated by Hypoxic Hepatitis

Background

Exertional heat stroke is a life-threatening condition often complicated by multiorgan failure. We hereby present a case of a 25-year-old male presenting with syncope after a 10  km run in 28°C outside temperature who developed acute liver failure. Case Presentation. Initial temperature was found to be 41.1°C, and cooling measures were rapidly applied. He suffered from acute renal failure and rhabdomyolysis and proceeded to acute liver failure (ASAT 6100 U/l and ALAT 6561 U/l) due to hypoxic hepatitis on day 3. He did not meet criteria for emergency liver transplantation and recovered on supportive care.

Conclusions

Acute liver failure due to heat stroke is a life-threatening condition with often delayed onset, which nevertheless resolves on supportive care in the majority of cases; thus, a delayed referral to transplant seems to be reasonable.

Acute immune responses are involved in liver and kidney injury in heat stroke

The changes in circulating cytokines throughout the progression of heat stroke–induced systemic inflammatory response syndrome have been thoroughly described. However, the innate and adaptive immune responses were poorly understood and are explored in this study. A classic heat stroke model in mice was constructed according to the established methods. The time course of splenic T helper cell plasticity, neutrophils, and macrophages in liver and kidney tissues were measured at 0, 24, and 72 h after onset of heat stroke. We showed heat stroke mice presented tachycardia and low mean arterial pressure and exhibited severe kidney and liver injury. Our data demonstrated that heat stroke could increase both the Th17 and Th22 response of splenic T helper cells and incremental infiltration of neutrophils and macrophages into liver and kidney tissues. Moreover, heat stroke could shift those macrophages into the M1 type. This study demonstrates for the first time the increasing splenic T helper response, changes in neutrophil and macrophage infiltration, and macrophage induction in response to heat stroke in mice. Our findings indicate that splenic T helper cells and local neutrophils and macrophages might be potential therapeutic targets for heat stroke.