Page 17 - Journal of Special Operations Medicine - Fall 2017

Exertional Heat Illness Resulting in
Acute Liver Failure and Liver Transplantation

Benjamin Boni, DO *; Christopher Amann, MD 2
1

ABSTRACT
Heat illness remains a large medical burden for militaries His initial pulse was 163 bpm, but his other vital signs were
around the world. Mitigating the incidence as well as the com- within normal limits. A primary survey was notable for an
plications of heat illness must remain on the forefront of op- obtunded state with a Glasgow coma scale (GCS) score of 3T.
erational planning when operating in hot environments. We A secondary survey revealed a 2cm forehead laceration with
report the case of a 27-year-old male U.S. Marine who sus- no other injuries. His initial laboratory values were notable
tained a heat-related illness resulting in fulminant liver failure for hyperkalemia (potassium, 5.9mmol/L), thrombocytopenia
and permanent disability. The patient was transferred from the (platelets, 71 × 10 /L), acute kidney injury (creatinine, 3.04mg/
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field to a civilian hospital. On hospital day 5, liver failure was dL), rhabdomyolysis (creatine kinase [CK], 1,199U/L), coagu-
identified. The patient was transferred to a transplant center, lopathy (international normalized ratio [INR], 1.6; fibrino-
where he successfully received a liver transplant. gen, 171g/L), and severe lactic acidosis (pH 7.13; lactate,
8.21mmol/L). He was given 1 ampule of sodium bicarbonate,
Keywords: heat-related illness; liver failure 1g of calcium gluconate, 10 units of insulin, and 1 ampule of
dextrose to treat his hyperkalemia. He was then resuscitated
with 5L of normal saline solution. Past medical history was
obtained from family and fellow Marines, who reported the
Introduction
patient had no chronic medical problems, no previous surger-
Environmental heat illness has been a medical burden for mili- ies, no allergies, and no chronic medication use.
taries since antiquity. Mentions of heat injury appear in writ-
ings about the Spartans, Alexander the Great’s campaigns, as The patient’s initial workup included computed tomography
1
well as the American Civil War. With today’s U.S. military (CT) scans of the head, cervical spine, thoracic spine, chest,
operations in the Middle East, Africa, Southeast Asia, and abdomen, and pelvis, which showed no acute traumatic injury
South America, heat illness remains an ever-present opera- or abnormalities, and he was admitted to the intensive care
tional consideration. unit. He subsequently developed signs of gastrointestinal (GI)
hemorrhage with bloody nasogastric tube output and mela-
In 2016, there were 401 cases of heat stroke and 2,135 cases of notic stools. A colonoscopy was performed on hospital day 2,
“other heat illness” among active Servicemembers of the U.S. which showed no evidence of ischemia or necrosis and only
2
Military. Due to the high frequency of heat illness encountered scattered petechiae in the ascending colon. An electrocardio-
by military medical providers, it is easy to become apathetic gram showed diffuse slow wave patterns but no evidence of
to the dangers of heat-related illness. This article reports the seizure activity. His urine output slowly declined and kidney
case of an active-duty Marine who sustained heat stroke that function worsened. He was started on hemodialysis for his
resulted in fulminant liver failure necessitating liver transplant. acute renal failure. The patient was also noted to have an up-
per extremity occlusive thrombus in the left basilic vein and
underwent placement of an inferior vena cava filter on hos-
Case Report
pital day 3.
A 27-year-old, male, active-duty U.S. Marine was participating
in a land navigation exercise in a desert environment in July. The next day he was found to have worsening deterioration of
The exercise began at 0600 and lasted 4 hours. The Marine his renal function (creatinine, 3.77mg/dL) and hepatic function
had been separated from his team and was found unrespon- (total bilirubin, 6.6μmol/L; aspartate aminotransferase [AST],
sive. Time down was unknown. His initial core temperature 11,870U/L; alanine aminotransferase [ALT], 8,810U/L). He
was 109°F (42.7°C). The medical records did not state what, developed pancreatitis (lipase, 5,095U/L), worsening rhabdo-
if any, specific cooling measures were performed in the field, myolysis (CK, 91,945U/L), and thrombocytopenia (platelets,
but the patient was emergently intubated in the field because 39 10 /L). On hospital day 5, his coagulopathy worsened and
9
of altered mental status and was transferred to the nearest he was diagnosed with fulminant liver failure with hepatic en-
hospital via helicopter. Upon arrival to a U.S. civilian hospi- cephalopathy, and was transferred to the nearest liver trans-
tal, his rectal temperature had decreased to 102.8°F (39.3°C). plant center.

*Correspondence to benjamin.d.boni.mil@mail.mil
1 LCDR Boni is a dive medical officer for the U.S. Navy and is an emergency medicine resident at Naval Medical Center San Diego, CA. LCDR
2
Amman is a dive medical officer for the U.S. Navy and is an emergency medicine resident at Naval Medical Center San Diego, CA.
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