A 29-year-old male patient was admitted to the hospital on May 3, 2023, at 13:00 because of a 2-hour history of altered consciousness. Physical examination revealed a body temperature of 40.0°C, pulse rate of 171 beats per minute, respiratory rate of 34 breaths per minute, blood pressure of 108/55 mmHg, and comatose state with a Glasgow Coma Scale (GCS) score of 4. Both pupils were equal in size and round, with a diameter of 3cm. They exhibited a normal response to light. Neck stiffness was observed (3 fingerbreadths), and coarse breath sounds were heard in both lungs, with slight moist rales in the lower lungs. The heart rate was 171 beats per minute, and heart sounds were audible without murmurs. The abdomen was flat and soft, without palpable liver or spleen below the ribs. Bowel sounds were diminished, and no shifting dullness was present. There was no edema in the lower limbs, but the patient had multiple abrasions on the skin. The muscle tone of all limbs was high, exhibiting rigidity, and muscle strength was graded as 0. Physiological reflexes were present, while pathological reflexes were absent. The patient collapsed after walking 9 kilometers rapidly two hours prior to admission, with subsequent loss of consciousness, unresponsiveness, fever, and no vomiting or seizures. The patient was urgently transported to our hospital, experiencing several seizures and urinary incontinence during the journey. Upon arrival at the emergency department, the body temperature was measured as 41°C, and symptomatic treatment including cooling measures was initiated. The patient had no significant medical history, adverse habits, or a history of smoking or alcohol consumption.
After admission, the following examinations were conducted: head and chest CT scans, which showed no obvious abnormalities in the brain and chest. A repeat scan was recommended to assess the right frontal sinusitis. The electrocardiogram (ECG) revealed sinus tachycardia, left atrial abnormality, and right bundle branch block. The blood routine examination showed a white blood cell count of 12.3×10^9/L, lymphocyte count of 4.13×10^9/L, and neutrophil percentage of 58.8%L. The lactate dehydrogenase (LDH) level was 385.4 U/L, creatinine level was 165.9 umol/L, uric acid level was 1173.7 umol/L, carbon dioxide level was 12.5 mmol/L. Liver function, myocardial enzyme spectrum, highly sensitive C-reactive protein (CRP), procalcitonin (PCT), IL-6, and TNF-α were all within normal range.
Considering the high possibility of heatstroke, the patient was subjected to physical cooling measures, including applying ice packs to major arteries (placed in the patient's armpits and groin), using a ice blanket machine, and administering rapid intravenous infusion of ice-cold saline solution, as a comprehensive antipyretic approach. The patient also received fluid resuscitation, gastric acid suppression, heart rate control, and treatment to reduce intracranial edema. With the effective and rapid resuscitation measures mentioned above, the patient's body temperature decreased to 38.0℃ within one hour, and vital signs stabilized. The cardiac monitoring showed a blood pressure of 117/64 mmHg, respiratory rate of 26 breaths per minute, and pulse rate of 117 beats per minute.
On the second day of admission (May 4), the patient's body temperature returned to normal, but the consciousness remained in a state of shallow coma. The blood routine examination revealed a white blood cell count of 13.1×10^9/L, lymphocyte count of 1.15×10^9/L, and neutrophil percentage of 83.5%. Biochemical examination revealed the following results: CK (Creatine Kinase) 2319 U/L, CK-MB (Creatine Kinase-MB) 85.1 U/L, Myo (Myoglobin) 1154 ng/ml, ALT (Alanine Aminotransferase) 102.5 U/L, AST (Aspartate Aminotransferase) 166.6 U/L, LDH (Lactate Dehydrogenase) 467.2 U/L, K (Potassium) 3.24 mmol/L, Na (Sodium) 147.8 mmol/L. The diagnosis is considered to include acute liver injury and myocardial damage, supporting the diagnosis of heatstroke. The patient will continue to receive aggressive fluid replacement therapy and gastroprotection to inhibit acid secretion. During the night of the same day, the patient experienced another episode of high fever with a temperature as high as 38.9°C. Physical cooling was applied using large arterial ice packs, and after 30 minutes, the body temperature returned to normal.
On the fourth day of admission (May 6), the patient continued to have a fever, with body temperature fluctuating between 36.6 and 38.0℃. The level of consciousness shifted from shallow coma to a state of confusion, and muscle pain and fatigue gradually appeared in the limbs. The blood routine examination showed a white blood cell count of 14.0×10^9/L, lymphocyte count of 0.54×10^9/L, and neutrophil percentage of 88.1%. Biochemical analysis revealed elevated levels of ALT (5675.2 U/L), AST (2897.3 U/L), Cr (103.7 umol/L), CRP (89.7 mg/L), PCT (16.92 ng/mL), IL-6 (186.7 pg/mL), and TNF-α (45.8 ng/L). The results indicate aggravated acute liver injury, rhabdomyolysis, and intensified systemic inflammatory response. Abdominal ultrasound examination showed no abnormalities. The patient received intravenous infusion of thiopronine and oral administration of silibinin capsules for liver protection and enzyme reduction, as well as cefoperazone sodium for anti-infective treatment. Fever reduction and fluid resuscitation were continued.
On the 9th day of hospitalization (May 11th), the patient no longer had a fever and was conscious. They were able to get out of bed and move around independently, with good mental state and appetite. Throughout the day, the highest recorded body temperature was 37.5℃. The patient experienced occasional coughing and expectorated yellowish, sticky sputum with a small amount of blood streaks. They also reported improvement in symptoms such as generalized muscle soreness and fatigue compared to before. The blood test results showed a white blood cell count of 5.5×10^9/L, lymphocyte count of 0.54×10^9/L, and a neutrophil percentage of 82.1%. In terms of biochemical analysis, the patient had an alanine aminotransferase (ALT) level of 697.7U/L, aspartate aminotransferase (AST) level of 265.2U/L, creatine kinase (CK) level of 2738U/L, creatine kinase-MB (CK-MB) level of 49.7U/L, C-reactive protein (CRP) level of 76.6 mg/l, procalcitonin (PCT) level of 0.7ng/ml, interleukin-6 (IL-6) level of 100.2pg/ml, and tumor necrosis factor-alpha (TNF-α) level of 34.9ng/L. The sputum culture and drug sensitivity test indicated the presence of carbapenem-resistant Acinetobacter baumannii growth. Based on the drug sensitivity results, the antibiotic was switched to oral minocycline capsules for anti-infection treatment. A consultation with the respiratory department was recommended to consider the addition of intravenous amikacin sulfate injection for combination anti-infection therapy. Following the proactive and effective treatment mentioned above, the patient's peak body temperature and various infection and inflammation indicators significantly decreased compared to before, suggesting the effectiveness of the treatment. Therefore, the treatment continued with intravenous fluid supplementation, liver protection and enzyme reduction, and comprehensive treatment to maintain water-electrolyte and acid-base balance.
On the 10th day of hospitalization (May 12th), the patient remained afebrile but still had a slight cough and expectorated a small amount of brownish sputum. The blood test results showed a white blood cell count of 8.0×10^9/L, lymphocyte count of 0.65×10^9/L, and a neutrophil percentage of 81.2%. In terms of biochemical analysis, the patient had an alanine aminotransferase (ALT) level of 409.4U/L, aspartate aminotransferase (AST) level of 123.9U/L, creatine kinase (CK) level of 707U/L, creatine kinase-MB (CK-MB) level of 46.0U/L, C-reactive protein (CRP) level of 68.1 mg/l, procalcitonin (PCT) level of 0.48ng/ml, interleukin-6 (IL-6) level of 34.5pg/ml, and tumor necrosis factor-alpha (TNF-α) level of 1.5ng/L. The chest CT scan shows that the infectious lesions in both lungs have decreased in absorption compared to the previous scan taken on May 8th, 2023, after treatment. There is also a reduction in the absorption of the small amount of pleural effusion in both sides compared to the previous scan. The patient's symptoms significantly improved compared to before, and the re-examination of relevant indicators and chest CT scan showed clear improvement. Treatment continued with targeted therapy for anti-infection, liver protection, and nutritional support. A consultation with the respiratory department was recommended to consider a transfer for specialized treatment, and the patient was transferred to the respiratory department in the afternoon to continue treatment. The trends of the patient's body temperature, ALT, AST, white blood cell count (WBC), neutrophil percentage (NEU%), CRP, PCT, IL-6, TNF-αlevels, and changes in lung CT images during hospitalization can be seen in Figures 1-6.