You are asked to examine a 68-year old man who is admitted unresponsive having
collapsed shortly after a family member took his picture (see below). Your examination
reveals an axillary temperature of 38.5 degrees centigrade, a pulse rate of 98 beats
per minute, a respiratory rate of 15 breaths per minute, and a blood pressure of 110/80
mm Hg. His skin is dry and erythematous and bilateral inspiratory crackles are audible
on lung examination. His neck is supple and there are no focal neurologic findings.
Pertinent laboratory findings include mildly abdormal liver function tests (elevated
SGOT, SGPT), an elevated creatinine kinase level, and findings compatible with a mild
disseminated intravascular coagulation disorder. A chest x-ray is characteristic of
an acute respiratory distress syndrome (ARDS).
What is your diagnosis, what test(s) would you order to confirm your suspicions,
and what treatment, if any, do you recommend?
DIAGNOSIS: Heat stroke.
The frequency and duration of heat waves in the United States has increased from
two in 1960 (lasting an average of 3 days) to six in the 2020s (lasting an average
of ~4 days). The health consequence of global warming are considerable with heat
waves being the most common cause of weather related deaths in the United States.
The presented case's diagnosis was delayed because of the unreliability of axillary
temperatures; a rectal temperature was subsequently measured at 40°C. All of the patient's
physical and laboratory findings may be present in patients with heat stroke.
A recent article by Bell and associates (see citation below) noted the increased
risk of multisystem disease during heat waves. This includes cardiovascular events
(myocardial infarction, congestive heart failure, arrythmia, and stroke), renal events
(kidney failure, stones, urinary tract infections), musculoskeletal disease (rhabdomyonecrosis),
birth outcomes (prematurity, low birth weight, stillborn), mental events (suicide,
anxiety), and respiratory disorders (asthma, acute respiratory distress syndrome).
Presyncope in a patient with heat stroke.
Citation: Bell, M.L., Gasparrini, A., Benjamin, G.C. Climate change, extreme heat, and health. N. Engl. J. Med 390(19):1793-1801, 2024.
.