(403) Acute Liver Failure: The Initial Presentation of Underlying Heat Stroke

Introduction: Acute Liver Failure (ALF) is described as severe liver injury with encephalopathy and coagulopathy in an individual without previously existing liver disease. A rare cause of hepatic hypoperfusion is underlying heat stroke; a disease characterized by multiorgan failure commonly presenting with elevated body temperatures and CNS dysfunction. Even though mild or moderate hepatic injury is a common manifestation of heat stroke, overt ALF is rarely described as the initial presentation. For this reason, in a patient presenting with ALF of unknown cause, a high index of suspicion is needed to rapidly identify and treat such complication. We herein present a case of a 65 y/o male patient that presented with multiorgan failure after suffering from a heat stroke in Puerto Rico.

Description: A 65-year-old male with unremarkable medical history came to the ED due to altered mentation, shortness of breath and fever. Laboratories showed coagulopathy (INR 1.65), AKI, elevated transaminases (AST 1160 U/L, ALT 668 U/L, ALP 142 U/L), CPK 6536 U/L, high ferritin and HLH panel negative. U/A with myoglobinuria without RBCs. He was admitted with the diagnostic impressions of AKI secondary to rhabdomyolysis, ALI and respiratory failure requiring intubation. Renal function returned to baseline while transaminitis worsened. Toxicology, acetaminophen levels, viral and autoimmune etiologies of hepatic injury were negative. Liver doppler showed no evidence of portal vein thrombosis. Upon re-evaluation of the patient’s presentation including altered mentation, hyperthermia and multi-organ failure during a heat wave in Puerto Rico, heat stroke was considered a possible etiology. After aggressive IVF hydration, he was successfully extubated and liver function tests returned to baseline.

Discussion: ALF as the presenting manifestation of heat stroke has been described in only a handful of cases, most of which have been secondary to exertion. Due to the heat wave present in Puerto Rico at the time of the patient’s presentation, it became clear that the culprit was secondary to non-exertional heat stroke. It is of vast importance to suspect heat-stroke-induced ALF in a patient with predisposing factors like older age and health disparities in order to provide effective management in a timely manner.