Heat stroke differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

Heat stroke must be differentiated from other disease that may cause alteration in mental status and hyperthermia including: Neuroleptic malignant syndrome, Malignant hyperthermia, Serotonin syndrome, and sepsis.

Differentiating Heat stroke from other Diseases

Differentiation between 2 types of heat stroke (Classic vs Exertional) is based on history, clinical findings, and laboratory findings. The following table summarizes their differentiating feature.

Characteristic Exertional Heat Stroke Classic Heat Stroke Age Adults Early childhood or elderly Health status Healthy and athlete Ill and debilitate Weather condition Temperate or hot Heat wave Activity Sustained or heavy exertion Sedentary Medications or drug use Ergogenic aids, ecstasy, cocaine Diuretics, β-blockers, antihistamines, antidepressants Sweating Present Abscent Laboratory findings Acid-base disturbance Metabolic acidosis Mixed metabolic and respiratory acidosis Calcium ↓ Nl Potassium ↓ or ↑ Nl Phosphate ↑ ↓ Blood glucose ↓ ↑ Creatine kinase (CK) ↑↑↑ ↑ AST, ALT ↑↑↑ ↑ Complications Rhabdomyolysis Severe Mild Acute renal failure Common (∼25%) Uncommon (∼5%)

Heat stroke must be differentiated from other conditions that may cause hyperthermia.

Disease Symptoms and signs Labs Other findings Heat stroke CNS dysfunction (disorientation, headache, irrational behavior, irritability, emotional instability, confusion, coma, or seizure) Hypotension and tachycardia Hyperventilation Weakness, nausea and vomiting, profuse sweating, dehydration. Electrolyte disturbances, increased CK, AST, and ALT Relevant history of excessive exercise and lack of water access Neuroleptic malignant syndrome Change in mental status Muscle rigidity Autonomic instability (labile BP, tachypnea, profuse sweating) Electrolyte disturbances, increased CK, LDH, ALP, AST, and ALT, leukocytosis, myoglobinuria. Relevant history of recent use of anti-psychotics Malignant hyperthermia Masseter muscle rigidity (early) Generalized muscle rigidity Sinus tachycardia Arrhythmia Hypercarbia (PaCO2) >65 mmHg, hyperkalemia History of receiving anaesthetic agent Serotonin syndrome Mental status changes (anxiety, agitated delirium, restlessness, and disorientation) Autonomic instability (diaphoresis, tachycardia,, hypertension, vomiting, and diarrhea) Neuromuscular hyperactivity (tremor, myoclonus, hyperreflexia, and bilateral Babinski sign) Elevated CK, LDH, ALP, AST, and ALT History of recent use of SSRIs, SNRIs , or MAOIs. Sepsis Altered mental status (confusion, altered consciousness, coma, or seizure) Respiratory rate ≥22/minute Systolic blood pressure ≤100 mmHg Thrombocytopenia, leukocytosis, leukopenia, elevated Cr References