{
  "abstract": "Exercise related heat illness (EHI) in young persons is rare in temperate regions. We report a case of EHI in a teenager who presented with acute liver failure (ALF), acute kidney injury (AKI) and rhabdomyolysis following vigorous physical activity. We also highlight the challenges of interpreting ammonia results if liver transaminases are elevated.A 15-year-old British male fell unconscious while on a 10 km run on a warm humid day. The weather conditions at the time of the run were 23 °C, humidity of 55%, and 6 mph wind speed. A passerby finding him pyrexial, dowsed him with water and moved him to a shaded area. Past medical history included well controlled asthma and a holiday to Egypt 2 weeks back.Paramedics on arrival noted tympanic temperature of 39.1 °C, tachycardia and delirium. He received fluid boluses and was intubated for transfer but extubated shortly after arrival to the hospital. Initial bloods showed deranged liver function, kidney tests and high troponin and creatinine kinase (CK), (figure 1). Full blood count was within normal limits. CT head was unremarkable and urine toxicology screen negative.He remained well and on day 3, while awaiting cardiac investigations was noticed to be jaundiced. His repeat bloods showed ALF with an International normalized ratio of 3, which remained unchanged despite parental Vitamin K. With an AKI, increasing increased ammonia and CK (figure 1), ALF protocol and N acetyl cysteine (NAC) infusion were initiated prior to transfer to the specialised liver centre.On arrival to the liver centre 76 hours post the initial insult, he had normal vitals and sensorium. Blood tests for liver and Kidney injury were beginning to improve and a normal ammonia was recorded (figure 1). Etiological work up for other causes of liver injury were negative (Infection, metabolic, autoimmune, genetic including mitochondrial diseases). He made a full recovery with supportive care and NAC infusion. Further genetic testing for malignant hyperthermia is negative.With the increasing risk of EHI due to climate change, this case highlights the importance of recognition, early cooling and need for blood test monitoring as severe organ injury may not be evident at onset.1 Ammonia may be inaccurately recorded high as in this case, if tested by wet enzymatic assay in presence of elevated liver transaminases (as at the admitting hospital). This has therapeutic implications as hemofiltration may be unnecessarily instituted. Laboratory wet chemistry ammonia analysis should include adequate sample blanking correction for accurate results2 (as at Liver unit) or be undertaken by dry chemistry methods.World Health Organisation recommends NAC for heat stroke induced ALF and may help by replenishing glutathione stores.3 Genetic testing for mutations that increase EHI susceptibility aids counselling.4 Assessment in controlled environment by sport physiologist is recommended for advice on heat acclimatisation, establishing a prevention plan and safe limits of physical activity for the individual.5 Abstract OC23 Figure 1Liver biochemical tests during course of illnessPrimary axis: ALT, ASTSecondary axis: RestReferences Ribeiro F, Bibi M, Pereira M, et al. Severe acute liver injury related to heat stroke. Eur J Case Rep Intern Med. 2020;1:001382.Herrera DJ, Hutchin T, Fullerton D, et al. Non-specific interference in the measurement of plasma ammonia: importance of using a sample blank. Ann Clin Biochem. 2010;47:81–3.i.13_n-acetylcysteine.pdf (accessed 27 October 2024)Sambuughin N, Mungunsukh O, Klein MG, et al. Genetics of exertional heat illness: revealing new associations and expanding heterogeneity. Int. J. Mol. Sci. 2024;25:11269.DeGroot DW, O’Connor FG, Roberts WO. Exertional heat stroke: an evidence-based approach to clinical assessment and management. Exp Physiol. 2022;107:1172–83.",
  "authors": [
    {
      "affiliations": [
        "Birmingham Children`s Hospital, UK"
      ],
      "name": "Judwin Ndzo"
    },
    {
      "affiliations": [
        "Birmingham Children`s Hospital, UK"
      ],
      "name": "Siddharth Mahesh"
    },
    {
      "affiliations": [
        "Birmingham Children`s Hospital, UK"
      ],
      "name": "Sarah Heap"
    },
    {
      "affiliations": [
        "Nottingham Children`s Hospital"
      ],
      "name": "Isaqe Qureshi"
    },
    {
      "affiliations": [
        "Birmingham Children`s Hospital, UK"
      ],
      "name": "Chayarani Kelgeri"
    }
  ],
  "title": "OC23 Case report: acute liver failure following exercise-related heat illness in a British teenager",
  "uid": "0d376406-18cf-52f0-bd2b-438a1db9ea39"
}