{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,25]],"date-time":"2026-04-25T09:40:00Z","timestamp":1777110000090,"version":"3.51.4"},"reference-count":46,"publisher":"BMJ","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Reports"],"accepted":{"date-parts":[[2018,7,14]]},"abstract":"<jats:p>A 31-year-old man was brought to Accident &amp; Emergency after collapsing during a race. On presentation, the patient had a temperature of 41.7\u00b0C (rectal). External cooling was started immediately. The patient was intubated in view of a Glasgow Coma Scale of 7 and was transferred to theintensive therapy unit. Laboratory results revealed an acute kidney injury, rhabdomyolysis, disseminated intravascular coagulopathy and acute liver failure. The patient was encephalopathic, jaundiced and difficult to sedate. His liver function continued to deteriorate with alanine aminotransferase (ALT) levels reaching 9207 U\/L. King\u2019s Hospital Liver Centre, London was contacted for a possible liver transplant, and they advised an infusion of N-acetylcysteine. The following day liver function tests improved; thus, transplantation was not performed. The patient failed multiple sedation holds and required a tracheostomy. He continued to spike a fever. Despite no source of sepsis being found, the patient remained on broad spectrum antibiotics to cover for any potential infective causes until day 27. After 15 days, the patient\u2019s encephalopathy gradually improved. He was weaned off the ventilator and underwent intense physiotherapy. The patient was discharged from hospital one month after admission.<\/jats:p>","DOI":"10.1136\/bcr-2018-224808","type":"journal-article","created":{"date-parts":[[2018,7,30]],"date-time":"2018-07-30T09:16:23Z","timestamp":1532942183000},"page":"bcr-2018-224808","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":8,"title":["Acute liver failure and hepatic encephalopathy in exertional heat stroke"],"prefix":"10.1136","volume":"2018","author":[{"given":"Audrey","family":"Aquilina","sequence":"first","affiliation":[{"name":"William Harvey Anaesthesia Department, East Kent Hospitals University NHS Foundation Trust, Ashford, UK"},{"name":"Anaesthesia and Intensive Care, Mater Dei Hospital, Msida, Malta"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tiziana","family":"Pirotta","sequence":"additional","affiliation":[{"name":"Anaesthesia and Intensive Care, Mater Dei Hospital, Msida, Malta"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andrew","family":"Aquilina","sequence":"additional","affiliation":[{"name":"Anaesthesia and Intensive Care, Mater Dei Hospital, Msida, Malta"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2018,7,30]]},"reference":[{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.1","doi-asserted-by":"publisher","DOI":"10.1213\/ane.0b013e3181a9d8d9"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.2","first-page":"1382","article-title":"Heatstroke: its clinical and pathological presentation, with particular attention to the liver","volume":"87","author":"Hassanein","year":"1992","journal-title":"Am J Gastroenterol"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.3","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1111\/j.1445-5994.1994.tb04433.x","article-title":"Hepatic failure in fatal exertional heatstroke","volume":"24","author":"Feller","year":"1994","journal-title":"Aust N Z J Med"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.4","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1016\/S0750-7658(97)84282-7","article-title":"[Fatal acute liver failure: a rare complication of exertion-induced heat stroke]","volume":"16","author":"Ichai","year":"1997","journal-title":"Ann Fr Anesth Reanim"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.5","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1097\/00004836-200006000-00015","article-title":"Fulminant hepatic failure from heat stroke requiring liver transplantation","volume":"30","author":"Berger","year":"2000","journal-title":"J Clin Gastroenterol"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.6","doi-asserted-by":"crossref","first-page":"1474","DOI":"10.1007\/s00134-004-2312-7","article-title":"Liver transplantation in exertional heat stroke: a medical dilemma","volume":"30","author":"Hadad","year":"2004","journal-title":"Intensive Care Med"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.7","unstructured":"Dio Cocceianus C. Heinemann W , Roman History (Cary E. & Foster HB trans). VI. London, 1914:269\u201371. Book LIII. https:\/\/ia802701.us.archive.org\/3\/items\/diosromanhistory06cassuoft\/diosromanhistory06cassuoft.pdf. (accessed 1 May 2018)."},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.8","doi-asserted-by":"publisher","DOI":"10.1007\/BF01711537"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.9","doi-asserted-by":"publisher","DOI":"10.1136\/jramc-141-03-06"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.10","doi-asserted-by":"crossref","first-page":"1978","DOI":"10.1056\/NEJMra011089","volume":"25","author":"Bouchama","year":"2002","journal-title":"The New England Journal of Medicine"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.11","doi-asserted-by":"publisher","DOI":"10.1023\/A:1006070708952"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.12","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-129-3-199808010-00001"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.13","doi-asserted-by":"publisher","DOI":"10.1093\/bja\/84.5.615"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.14","doi-asserted-by":"publisher","DOI":"10.1097\/00006123-200208000-00002"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.15","doi-asserted-by":"crossref","first-page":"1448","DOI":"10.7205\/MILMED-D-12-00351","article-title":"Dietary supplements and warfighters: a challenge for military providers","volume":"177","author":"O\u2019Connor","year":"2012","journal-title":"Mil Med"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.16","unstructured":"Knochel JP , Reed G . Disorders of heat regulation. Clinical Disorders of Fluid and Electrolyte Metabolism 1994:1549\u201390."},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.17","doi-asserted-by":"publisher","DOI":"10.1007\/s001340050787"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.18","doi-asserted-by":"publisher","DOI":"10.1016\/S0303-8467(97)00106-6"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.19","first-page":"653","article-title":"pharmacodynamics and drug monitoring in acute illness","volume":"55","author":"Short","year":"1998","journal-title":"British Medical Bulletin"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.20","doi-asserted-by":"publisher","DOI":"10.2165\/00003495-199243040-00007"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.21","doi-asserted-by":"publisher","DOI":"10.1249\/JSR.0b013e31825615cc"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.22","doi-asserted-by":"publisher","DOI":"10.1136\/jramc-151-04-04"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.23","doi-asserted-by":"publisher","DOI":"10.1136\/bjsm.2004.013466"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.24","doi-asserted-by":"crossref","first-page":"613","DOI":"10.7326\/0003-4819-130-7-199904060-00025","article-title":"Features and Outcomes of Classic Heat Stroke","volume":"130","author":"Graham","year":"1999","journal-title":"Ann Intern Med"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.25","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-132-8-200004180-00023"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.26","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(80)92764-6"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.27","doi-asserted-by":"crossref","first-page":"614","DOI":"10.7326\/0003-4819-130-7-199904060-00009","article-title":"Features and outcomes of classic heat stroke","volume":"130","author":"Slovis","year":"1999","journal-title":"Ann Intern Med"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.28","doi-asserted-by":"publisher","DOI":"10.1378\/chest.104.2.411"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.29","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMra1208937"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.30","unstructured":"Lee WM , Larson AM , Stravitz RT . AASLD Position Paper: the management of acute liver failure update 2011. The American Association for the Study of Liver Diseases 2011 http:\/\/www.aasld.org\/sites\/default\/files\/guideline_documents\/alfenhanced.pdf (Accessed: May 2018)."},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.31","doi-asserted-by":"crossref","first-page":"831","DOI":"10.1007\/BF01709530","article-title":"Liver transplantation in a case of fulminant liver failure after exertion","volume":"22","author":"Saissy","year":"1996","journal-title":"Intensive Care Med"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.32","doi-asserted-by":"publisher","DOI":"10.1002\/lt.20400"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.33","unstructured":"Knochel JP . Exertional heat stroke-pathophysiology of heat stroke. In: Hopkins PM , Ellis FR , eds. Hyperthermic and Hypermetabolic Disorders. Cambridge: Cambridge University Press, 1996:42\u201362."},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.34","doi-asserted-by":"publisher","DOI":"10.1097\/00003246-199708000-00017"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.35","first-page":"816","article-title":"Increased survival in experimental dog heatstroke after reduction of gut flora","volume":"50","author":"Bynum","year":"1979","journal-title":"Aviat Space Environ Med"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.36","doi-asserted-by":"publisher","DOI":"10.1152\/japplphysiol.00886.2003"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.37","doi-asserted-by":"crossref","first-page":"496","DOI":"10.7205\/MILMED-D-02-5908","article-title":"Exertional heatstroke: early recognition and outcome with aggressive combined cooling--a 12-year experience","volume":"174","author":"Sithinamsuwan","year":"2009","journal-title":"Mil Med"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.38","doi-asserted-by":"publisher","DOI":"10.1249\/01.mss.0000227302.80783.0f"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.39","first-page":"1","article-title":"Exertional heat stroke in a young military trainee: is it preventable?","volume":"3","author":"Wijerathne","year":"2016","journal-title":"Mil Med Res"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.40","doi-asserted-by":"publisher","DOI":"10.1016\/j.jhep.2008.08.009"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.41","doi-asserted-by":"publisher","DOI":"10.1055\/s-2007-1007252"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.42","doi-asserted-by":"publisher","DOI":"10.1016\/S0016-5085(03)01051-5"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.43","doi-asserted-by":"crossref","first-page":"925","DOI":"10.1016\/j.cgh.2012.04.011","article-title":"Persistent hyperammonemia is associated with complications and poor outcomes in patients with acute liver failure","volume":"10","author":"Kumar","year":"2012","journal-title":"Clin Gastroenterol Hepatol"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.44","doi-asserted-by":"crossref","first-page":"664","DOI":"10.1016\/j.cgh.2012.02.016","article-title":"Acute Liver Failure Study Group Germany, Etiologies and outcomes of acute liver failure in Germany","volume":"10","author":"Hadem","year":"2012","journal-title":"Clinical Gastroenterology and Hepatology"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.45","doi-asserted-by":"publisher","DOI":"10.1016\/0168-8278(91)90900-V"},{"key":"2025082803310288000_2018.jul27_1.bcr-2018-224808.46","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1016\/j.jceh.2015.01.004","article-title":"Antibiotics in Acute Liver Failure (ALF)","volume":"5","author":"Shalimar","year":"2015","journal-title":"J Clin Exp Hepatol"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2018-224808","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,28]],"date-time":"2025-08-28T10:31:14Z","timestamp":1756377074000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2018-224808"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2018,7,30]]},"references-count":46,"alternative-id":["10.1136\/bcr-2018-224808"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2018-224808","relation":{},"ISSN":["1757-790X"],"issn-type":[{"value":"1757-790X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2018,7,30]]}}}