A 36-year-old female who had been running a marathon was brought to the emergency department (ED). She was brought in by the Civil Defence ambulance after she had collapsed at the 10 km mark. According to bystander accounts, she was unresponsive, trembling and her eyes were rolling up. There was no jerking of the limbs to suggest a generalised seizure according to the paramedics.
The patient's sister, who was running ahead of her, said that the patient had been well before the marathon and that both had flown in from Australia for the event. The patient used to run regularly, but shorter distances.
On arrival, the patient was noted to be obviously confused and disorientated, and kept trying to get off the bed. Her rectal temperature was 41.6°C initially and dropped to 38.4°C at the emergency department. The heart rate was 120 beats/min, blood pressure was 91/48 mmHg, and the oxygen saturation was 98% on room air. Normal saline was administered through an iv cannula in the left antecubital fossa. The cardiovascular and abdominal examination was unremarkable. She was able to move all four limbs, and her pupils were equal and reactive to light.
She was noted to have extensive scarring all over her trunk and upper limbs except the hands and the upper part of her face. Previous case records showed that she had sustained deep second and third degree burns over 49% of her body 5 years earlier. This condition was complicated by the development of a deep vein thrombosis of the right lower limb. The cicatrised skin was noted to be rubbery, firm, dry and shiny (Figure 1).
Rapid evaporative cooling using wet gauze to moisten the skin and pedestal fans at 22°C was employed. One litre of normal saline was infused via two intravenous lines. The patient became progressively calmer, but stayed amnesic throughout her stay at the ED.
Her renal function, liver function and coagulation profile remained within normal limits at all times. Electrolytes showed the presence of some compensated metabolic acidosis (pH 7.40); pCO2 was 28.2 mmHg, pO2 98 mmHg and serum bicarbonate 16 mmol/l. Base excess was -7.3 (normal -2 to +2). Her creatinine kinase levels peaked at about 2,096 U/l (range: 38 - 164 U/l) before trending downwards. The urine myoglobin level was noted to be a maximum of 100 UG/l (normal < 21 UG/l).
The patient was admitted to the medical ward and stayed there for 3 days. She regained her normal mental state by the evening of the same day. She was eventually discharged with advice to refrain from participating in any such endurance events because of her singular physiology.