The coagulopathy of heat stroke: alterations in coagulation and fibrinolysis in heat stroke patients during the pilgrimage (Haj) to Makkah.

Haemostatic measurements were undertaken in 132 patients diagnosed with heat stroke during the pilgrimage to Makkah, in two successive summers of 1989-90. The control group comprised 49 patients, all pilgrims, with a wide range of clinical conditions, but without hyperpyrexia or deranged haemostasis. Heat stroke patients showed (i) significant prolongation of the prothrombin (PT), activated partial thromboplastin (aPTT) and thrombin times (TT) but normal reptilase time (RT); (ii) significant reduction in plasma levels of antithrombin III (AT-III), factor V, proteins C and S, plasminogen activator inhibitor (PAI) and platelet count; (iii) increase in plasma factor VIII, tissue plasminogen activator (t-PA) and serum FDP; (iv) no significant changes in plasma fibrinogen, plasminogen, alpha 2-antiplasmin and factors VII and X. Heat stroke patients were then grouped into those with and those without bleeding symptoms. Bleeders showed greater prolongation of the PT, aPTT and TT and significant reductions in fibrinogen, AT-III, factors V, VIII and X, plasminogen, alpha 2-antiplasmin and platelet count. Logistic regression and discriminant analysis showed that AT-III was the parameter associated most with heat stroke and reliable enough to predict its occurrence, whether or not bleeding occurred. The results indicate that activation of the haemostatic mechanism, consumptive in nature, regularly accompanies heat stroke and highlights the physiological role of AT-III in checking this activation process.

Invasive evaluation of patients with heat stroke.

Right-heart catheterization was performed in ten patients who suffered heat stroke on their pilgrimage to Mecca, Saudi Arabia. The group included seven men and three women who had mean rectal temperatures of 42.4 degrees C. Other findings included the following: heart rate (mean, 120 beats/min); cardiac output (mean, 8.2 ml/min/m2); arterial pressure (mean, 65 mm Hg); cardiac indices (mean, 4.4 ml/min/m2); right atrial pressure (mean, 6 mm Hg); pulmonary capillary wedge pressure (mean, 10 mm Hg); systemic vascular resistance (mean, 684 dyne.s.cm-5); pulmonary vascular resistance (mean, 86 dyne.s.cm-5); oxygen delivery (mean 837 ml/min/m2); oxygen consumption (mean 160 ml/min/m2); mixed venous oxygen tension (mean, 56 mm Hg); and shunt fraction (mean, 20 percent). Nine patients survived. One, who had a cardiopulmonary arrest before any treatment could be administered, died.

Non-invasive evaluation of cardiac abnormalities in heat stroke pilgrims.

Serial electrocardiograms as well as echocardiographic studies of 51 pilgrims suffering from acute heat stroke (mean rectal temperature 41.6 degrees C) were performed. All patients were examined immediately after cooling and 24 h later whenever possible. Regional wall motion abnormalities were detected in 9 cases (17.6%) while pericardial effusion was observed in 13 cases (25%) and asymmetrical septal hypertrophy was detected in 8 cases (15.6%). Other cardiac abnormalities included right ventricular dilatation and increased in left ventricular internal dimensions in 4 cases (7.8%), respectively. Thirteen cases (25.5%) had normal echocardiographic findings. Forty (78%) patients had sinus tachycardia while 8 cases (15.7%) showed atrial fibrillation with uncontrolled ventricular rate, and 3 (5.8%) had sinus bradycardia. Heat stroke electrocardiograms showed tracings demonstrating ST segment depression, compatible with ischaemia in 9 cases, while in 6 cases there were nonspecific T wave changes, whereas in another 4 cases the tracings demonstrated different conduction abnormalities. The collected data were analysed and compared to those of 43 control patients. The adverse effects of heat stroke on the heart are multifactorial requiring the utmost attention and understanding, as they reflect the patient's cardiovascular status.

Aneurysmal dilatation of the coronary arteries: diagnostic patterns and clinical significance.

In order to define the clinical features, clinical patterns and significance of aneurysmal dilatation of the coronary arteries, five cases are presented which were diagnosed by coronary angiography. Three cases presented with left ventricular dysfunction secondary to coronary arterial occlusive disease and the fourth patient presented with thromboembolic cerebrovascular disease. The fifth case presented with manifestations of acute myocardial infarction.

Are heat stroke patients fluid depleted? Importance of monitoring central venous pressure as a simple guideline for fluid therapy.

During pilgrimage season (Hajj) in Saudi Arabia 34 patients with heat stroke (HS) were centrally cannulated to assess their state of hydration and fluid requirement during cooling period. Central venous pressure (C.V.P.) measurements indicated that most victims of heat stroke had normal C.V.P. on arrival at heat stroke centres and may not be fluid depleted. Twenty-two patients (64.7%) had normal or above normal C.V.P. Twelve patients (35.3%) had zero or below zero C.V.P. Six patients (17.6%) had above 10 cmH2O (range 10-26 cmH2O) and could have developed acute congestive heat failure and pulmonary edema if they had been transfused at the standard recommended rate of 3-4 litres of fluid during an average cooling time of 1 h as has been practiced in the heat stroke centres to date. This study also showed that heat stroke patients should not be briskly transfused because the heart may be affected by heat stroke per se and an unmonitored challenge by brisk i.v. therapy during cooling (which on its own increases preload on the heart due to peripheral vasoconstriction) can lead to acute overload problems. An average of 1 litre of normal saline or Ringer's lactate (crystalloids) was sufficient to normalize C.V.P. during the cooling period and to restore an optimal state of hydration without predisposing to congestive cardiac failure and pulmonary edema--the potential to develop disastrous adult respiratory distress syndrome and disseminated intravascular coagulopathy.

Metabolite and hormonal profiles in heat stroke patients at Mecca pilgrimage.

Sera obtained during the Hajj seasons of 1985, 1986, 1987 and 1988 from 125 heat stroke patients were collected and subjected to chemical analysis which included determination of glucose, lactate, cholesterol, and triglycerides, as well as assay of T3, T4, TSH and cortisol. Hyperglycaemia and lactic acidaemia were found to be the most frequent metabolic abnormalities. The changes in cholesterol did not exhibit a specific pattern. Triglycerides were significantly elevated in only 6% of patients. Cortisol levels were very significantly elevated in precooled patients. Although the mean T3 levels remained within the normal range, the mean concentration on admission was significantly higher than the post-cooling mean. TSH and T4 levels did not show significant changes.

The morbidity and mortality pattern of Brucella endocarditis.

Six cases of well-documented Brucella endocarditis are reported. All the patients gave a history of ingestion of raw milk and/or being in contact with sheep and/or camels during herding. The diagnosis was based in each case on a history of ingestion of raw milk, high titres of Brucella antibodies, a positive blood culture and echocardiography. A combination of tetracycline, rifampicin and streptomycin was found to be effective in eradicating the Brucella organism. Two cases required aortic valve replacement, and another two required replacement of both aortic and mitral valves. One case died before any surgical intervention could be performed and one patient did not require surgery. Although it was noted that the Brucella organism attacks mainly valves which are already damaged, it may also attack and infect normal valves.

Joint mobility and mitral valve prolapse in an Arab population.

The association of joint laxity and mitral valve prolapse (MVP) has been disputed. In this study of an Arab population, the joint mobility scores of 29 subjects with MVP, 10 of whom were asymptomatic, were compared to 60 normal controls. It was found that the joint mobility score was significantly higher in both the asymptomatic and the symptomatic subjects with MVP when compared to the controls. This suggests that both mitral valve prolapse and joint laxity may be due to the same abnormality of connective tissue structure.

Association of brucella endocarditis with intracerebral haemorrhage.

We describe a case of brucella endocarditis which was strongly suspected on clinical grounds and subsequently confirmed by bacteriological, serological and echocardiographic investigations. The endocarditis, in a 42-year-old Saudi male, was complicated by intracerebral haemorrhage, presumably from a ruptured mycotic aneurysm. Although such a complication is well documented in other forms of infective endocarditis, it has not been reported in brucellosis.

Heat stroke at the Mekkah pilgrimage: clinical characteristics and course of 30 patients.

The clinical picture and the final outcome of 30 patients with heat stroke during the Mekkah pilgrimage 1404 (September 1984) were analysed. Rapid cooling by the 'evaporative method' was achieved in a mean time of 59 min (range 15-135). An initial temperature above 42 degrees C and a cooling time of more than 1 h indicated a poor prognosis. Acute hepatic failure, 'adult respiratory distress syndrome' and decerebrate convulsions were among the fatal complications occurring in three patients. In the final outcome three patients (10 per cent) died, two patients (7 per cent) recovered but developed myocardial infarction and cerebellar ataxia respectively. Twenty-five patients (83 per cent) made an uncomplicated recovery.

Acute myocardial infarction with normal coronary angiograms.

I report a case of acute myocardial infarction, confirmed by electrocardiographic features as well as by raised cardiac enzymes and history of left-sided chest pain, which occurred in a 19-year-old student. There were no predisposing factors and selective coronary angiography was normal.