Non Exertional Heat Stroke

and Elevated TroponinMaria Batool M.D

Anushree Agarwal M.D

Krishna Nagendren M.D

Aurora Health Care Internal Medicine Residency Program

51 year old female admitted to the ER

c/c: Altered mental status

HPI: Patient was living in a old house with no central air

conditioning and was reportedly doing well until the day

before

PMH:

Diabetes

Asthma

Well-controlled HTN

Bipolar disorder

Schizophrenia

Case Presentation

Social History:

No alcohol or drug use

Medications:

Valsartan

Metoprolol

Metformin

Quetiapine

Lithium

Fluphenazine

Further History

BP: 129/ 65 mmHg

PULSE: 96/min

RR: 22/min

FiO2: 60%

TEMP: 108.1 Fahrenheit !!!! (rectal)

Vital Signs

Obese female, intubated and sedated

Pupils 2 mm size and sluggishly reactive to light

No muscle rigidity

Reflexes hypoactive

Otherwise normal exam

Physical Exam

Lab Data

CBC

9.2

• BNP: 156• Myoglobin: 232 ng/ ml• CK-MB: 1.6 ng/ ml

BMP

137 105 21

5.5 22 2.00 222

• CPK: 96 units/L

• Troponin: 0.16 ng/ ml

• UDS: negative

18.6 478

29.9

Initial EKG showed sinus tachycardia with non-

specific T wave abnormality in the anterior leads

Subsequent EKG showed normal sinus rhythm

EKG

Heat Stroke

Temp > 40° C

CNS Dysfunction

Non Exertional

Cooling Measures

Hemodynamic Support

Exertional

Increased Temperature+ Thermoregulatory

Failure

Increased rate of enzymatic

reactions

Cellular denaturation/

death

Tissue ischemia

Multi-organ dysfunction

Pathophysiology

Clinical Presentation

PHYSICAL FINDINGS

Flushing (cutaneous

vasodilation)

Tachypnea

Excessive bleeding

Altered mentation or

seizures

LAB FINDINGS

Leukocytosis

Hemo concentration

Evidence of DIC

Hypokalemia/ hyperkalemia

Lactic acidosis

Elevated transaminases

Cooling blankets, infusion of cold saline and aggressive

hydration

Extubated within 48 hours

Continued to have confusion and agitation- treated with

Haldol and Lorazepam

Troponin continued to trend up in spite of overall

improvement

Back to the patient….

Troponin Level

0.16

3.39

12.38

11.15

8.79

6.28

22.4

1.8

1.40

2

4

6

8

10

12

14

19-Jul 20-Jul 21-Jul 22-Jul

cTnI - ng/ ml

Creatinine mg/ dl

108.1

102.5 101.8

96

105

95

97

99

101

103

105

107

109

19-Jul 20-Jul 21-Jul

Temp(F)

CPK - units/ L

Temperature

Increased cardiac output (cardiac output increases

about 3 L/min for each 1°C )

Severe sepsis-like syndrome

Neural mediation

Ventricular strain

Coronary endothelial dysfunction

Mechanism of Troponin

Elevation

Very few case reports about troponin elevation and it’s

significance in heat stroke, especially non exertional

heat stroke

Troponin levels significantly elevated in non-survivors

of heat stroke(1) (7.4 vs 1.1 ng.mL-1, P < 0.01)

No reports, to our knowledge, of cardiac catheterization

demonstrating normal coronary arteries in patients of

heat stroke

1. Early organ dysfunction course, cooling time and outcome in classic heatstroke..Intensive Care Med. 2009 Aug;35(8):1454-8. Epub 2009 Apr 29. Pease S, Bouadma L, Kermarrec N, Schortgen F, Régnier B, Wolff M.

Troponin and Heat stroke

Patient started on ACS protocol

Cardiology consulted

2D –ECHO - Normal

Cardiac catheterization - Clean coronaries

Patient Course

Troponin elevation is an independent adverse prognostic

factor in heat stroke(1)

Troponin elevation in heatstroke patients is rarely related

to anatomic coronary lesions

Severe increases in troponin ( > 1.5 ng /ml) indicate

severe myocardial damage(1)

Early identification of prognostic variables in the ER is

essential to determining the therapeutic priorities

1. Elevation of cardiac troponin I during non-exertional heat-related illnesses in the context of a heatwave. Crit Care. 2010;14(3):R99. Epub 2010 May 27.

Conclusion

Hausfater P, Doumenc B, Chopin S, Le Manach Y, Santin A, DauthevilleS, Patzak A, Hericord P, Mégarbane B, Andronikof M, Terbaoui N, Riou B. Elevation of cardiac troponin I during non-exertional heat-related illnesses in the context of a heatwave. Crit Care. 2010;14(3):R99. Epub 2010 May 27.

Hausfater P, Megarbane B, Dautheville S, Patzak A, Andronikof M, SantinA, André S, Korchia L, Terbaoui N, Kierzek G, Doumenc B, Leroy C, Riou B.Prognostic factors in non-exertional heatstroke. Intensive Care Med. 2010 Feb;36(2):272-80. Epub 2009 Oct 20.

Hausfater P, Hurtado M, Pease S, Juillien G, Lvovschi VE, SalehabadiS, Lidove O, Wolff M, Bernard M, Chollet-Martin S, Riou B. Is procalcitonin a marker of critical illness in heatstroke? Intensive Care Med. 2008 Aug;34(8):1377-83. Epub 2008 Mar 28.

Ibrahim A Hashim. Clinical biochemistry of hyperthermia. Ann Clin Biochem2010; 47: 516–523. DOI: 10.1258/acb.2010.010186.

References

Thank you!