Fulminant hepatic failure accompanied by fatal rhabdomyolysis following exertional heatstroke

We present a previously healthy 38-year-old Japanese man who developed exertional heatstroke (EHS) following a long-distance run and presented with fulminant hepatic failure (FHF) accompanied by a life-threatening flare-up of rhabdomyolysis. Intensive life-supporting medical procedures, including plasma exchange, hemodiafiltration, steroid pulse therapy, and anticoagulant treatment enabled the patient to survive FHF. Initially, his general condition was thought to be improving; however, smoldering rhabdomyolysis suddenly flared up with a marked increase in creatine kinase levels when the dose of steroids was reduced, subsequent to which his condition deteriorated rapidly, eventually resulting in death. The serum levels of interleukin-6 measured retrospectively were found to be markedly elevated and to have fluctuated synchronously with the disease activity. This case report demonstrates that EHS can cause FHF and severe rhabdomyolysis, the outcome of which was tragic even though FHF was substantially well managed; however, the clinical evidence suggests the possible therapeutic efficacy of steroid therapy for refractory rhabdomyolysis occurring in EHS.