Hyperthermia (Exertional Heat Stroke) Induced Seizure - Rugby

HISTORY: A 20-year-old male sustained a seizure. Player was running in his second match for the day, during the third tournament of a four-event series. Location was upstate NY, temperature 78.1 °F, winds 3.4 mph west with haze and mild smoke. While running, player moved to sideline, started grabbing head, stated he felt dizzy, and collapsed. Staff rushed over, and he convulsed. Placed on his side, he convulsed for 1.5 min. Postictal state included confusion and sluggishness. Patient warmed up for an hour and played 24 match minutes over 1.5 hours of the tournament. No medical history or neuromuscular condition, and no medications. Patient was spine-boarded and sent to the ED by ambulance, presenting with headache, sluggishness, and confusion post-seizure. Provisionally diagnosed with heat-induced seizure, placed in monitored ED unit with IVs, started on benzodiazepines. MRI showed no gross abnormalities, tumor, or AV malformations. PHYSICAL EXAMINATION: ED exam revealed young male with memory deficit, tachypnea, and tachycardia. Mild eye twitching, no difficulty breathing, good air entry bilaterally. General weakness in arms and legs, headache, and thirst. Limited range of motion postictal. Strong radial pulses, poor capillary refill, decreased sensation, reflexes, and strength in extremities. DIFFERENTIAL DIAGNOSIS: 1. Hyperthermia 2. Heat Exhaustion/Fatigue 3. Heat Stroke 4. Exertional Heat/Rhabdomyolysis Induced Seizure-like Activity 5. Malignant Hyperthermia: Environmental Heat TESTS AND RESULTS: BP 105/68, HR 103, RR 25, T 99 °F. Labs showed WBC 35,000/uL, Na 126 mmol/L, K 5.5 mmol/L, CO₂ 32 mmol/L, BUN 28 mg/dL, Creatinine 1.2 mg/dL, Glucose 46 mg/dL, CK 111,000 IU/mL. Urinalysis: dark, myoglobinuria. MRI Brain (no contrast): transient T2 and FLAIR signal increase in left temporal lobe cortex or subcortical white matter, with some mass effect. Normal ventricles, no midline shift, no hydrocephalus. FINAL WORKING DIAGNOSIS: Hyperthermia (Exertional Heat Stroke) induced seizure. TREATMENT AND OUTCOMES: 1. Emergency treatment delayed in field. 2. IV fluids prior to lab correction; monitor hyperkalemia 3. Patient recovered due to age. 4. No return to sport.