S5913 Running into Trouble: A Case of Acute Liver Failure From Severe Rhabdomyolysis After a Marathon

Introduction: Rhabdomyolysis-induced acute fulminant liver failure is a rare but life-threatening complication, often triggered by extreme physical exertion. We present the case of a healthy young adult who developed acute fulminant liver failure and renal failure following marathon-associated heat stroke and rhabdomyolysis, possibly exacerbated by adderall use. Case Description/Methods: A 21-year-old man with a history of attention deficit hyperactivity disorder on adderall presented with altered mental status during a marathon after reportedly ingesting adderall mid-race. On arrival, he was encephalopathic, diaphoretic, hyperthermic, and subsequently intubated. Labs revealed severe rhabdomyolysis (CK >266,000), acute liver injury (aspartate aminotransferase 13,305, alanine aminotransferase 5,393), acute kidney injury (Cr 7.8), coagulopathy (international normalized ratio 2.5, platelets 47), and elevated ammonia (156). Imaging showed hepatomegaly and signs of nonspecific enteritis. The patient was treated with N-acetylcysteine, hemodialysis, lactulose, and supportive intensive care unit (ICU) care. A liver biopsy revealed regenerative changes with mild fibrosis. Mental status improved, and he was successfully extubated. Despite initial deterioration (MELD-Na peaked at 32), the patient showed remarkable recovery with normalization of LFTs and improved renal function. Discussion: This case highlights the synergistic toxicity of exertional heat stress, sympathomimetic use (adderall), and rhabdomyolysis, culminating in acute multi-organ failure. Clinicians should maintain high suspicion for rhabdomyolysis-related acute liver failure in patients with exertional collapse, especially with stimulant use. While rhabdomyolysis is typically associated with renal complications, this case underscores its potential to precipitate acute liver failure. Prompt recognition, early ICU intervention, and multidisciplinary management can lead to full recovery even in fulminant presentations.