The consequences of delay: Diagnostic challenges and critical care gaps in a patient with exertional heatstroke at a mass gathering

Introduction: Exertional heatstroke (EHS) is a medical emergency characterized by an elevated core body temperature and central nervous system dysfunction. If not identified and treated early, it can rapidly progress to multiple organ dysfunction. Although EHS is common among athletes and military personnel, it may also affect vulnerable individuals during mass gatherings in extreme environmental conditions, such as the Hajj pilgrimage. Case Presentation: We report a fatal case of EHS in a previously healthy 56-year-old male pilgrim during the 2024 Hajj season. The patient collapsed after prolonged physical exertion in high ambient temperatures and was initially misdiagnosed with hemorrhagic stroke, resulting in an 8-h delay in definitive management. Upon arrival at the Indonesian Hajj Health Clinic in Mecca, he presented with coma, hyperthermia (42°C), metabolic acidosis, acute liver failure, coagulopathy, and acute kidney injury requiring hemodialysis. Despite intensive care, including cooling interventions and organ support, the patient died on the fifth day of admission due to refractory hyperthermia and progressive organ failure. Discussion: This case highlights the diagnostic challenges of EHS in high-risk environments, where its symptoms may mimic other critical conditions such as stroke. Delays in initiating rapid cooling and systemic support can significantly worsen the prognosis. Early recognition, accurate differentiation from other acute neurologic conditions, and aggressive intervention are essential to reduce EHS-related morbidity and mortality. Conclusion: Timely diagnosis and immediate cooling are crucial to improving outcomes in EHS. Preventive education, heat-risk awareness, and clinical preparedness are essential during mass gatherings to reduce fatalities associated with heat-related illnesses.