Heat stroke differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2],Usama Talib, BSc, MD [3]


Heat stroke must be differentiated from other disease that may cause alteration in mental status and hyperthermia including: Neuroleptic malignant syndrome, Malignant hyperthermia, Serotonin syndrome, cocaine use and sepsis.[1][2][3][4][5][6]

Differentiating Heat stroke from other Diseases

Differentiation between 2 types of heat stroke (Classic vs Exertional) is based on history, clinical findings, and laboratory findings.[7][8] The following table summarizes their differentiating feature.

Characteristic Exertional Heat Stroke Classic Heat Stroke
Age Adults Early childhood or elderly
Health status Healthy and athlete Ill and debilitate
Weather condition Temperate or hot Heat wave
Activity Sustained or heavy exertion Sedentary
Medications or drug use Ergogenic aids, ecstasy, cocaine Diuretics, β-blockers, antihistamines,


Sweating Present Abscent
Laboratory findings Acid-base disturbance Metabolic acidosis Mixed metabolic and respiratory acidosis
Calcium Nl
Potassium ↓ or ↑ Nl
Blood glucose
Creatine kinase (CK) ↑↑↑
AST, ALT ↑↑↑
Complications Rhabdomyolysis Severe Mild
Acute renal failure Common (∼25%) Uncommon (∼5%)

Differentiating Heat stroke from other Diseases that may cause hyperthermia and altered mental status

Heat stroke must be differentiated from other conditions that may cause hyperthermia and altered mental status.[1][2][3][4][5][6]

Disease Symptoms and signs Labs Other findings
Heat stroke Electrolyte disturbances, increased CK, AST, and ALT Relevant history of excessive exercise and lack of water access
  • Altered mental status (confusion, altered consciousness, coma, or seizure)
  • Respiratory rate ≥22/minute
  • Systolic blood pressure ≤100 mmHg
Thrombocytopenia, leukocytosis, leukopenia, elevated Cr
Malignant hyperthermia Hypercarbia (PaCO2) >65 mmHg, hyperkalemia History of receiving anaesthetic agent
Neuroleptic malignant syndrome Electrolyte disturbances, increased CK, LDH, ALP, AST, and ALT, leukocytosis, myoglobinuria. Relevant history of recent use of anti-psychotics
Serotonin syndrome Elevated CK, LDH, ALP, AST, and ALT History of recent use of SSRIs, SNRIs , or MAOIs.


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  2. 2.0 2.1 Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, Rubenfeld G, Kahn JM, Shankar-Hari M, Singer M, Deutschman CS, Escobar GJ, Angus DC (2016). "Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)". JAMA. 315 (8): 762–74. doi:10.1001/jama.2016.0288. PMC 5433435. PMID 26903335.
  3. 3.0 3.1 Carbone JR (2000). "The neuroleptic malignant and serotonin syndromes". Emerg. Med. Clin. North Am. 18 (2): 317–25, x. PMID 10767887.
  4. 4.0 4.1 Bodner RA, Lynch T, Lewis L, Kahn D (1995). "Serotonin syndrome". Neurology. 45 (2): 219–23. PMID 7854515.
  5. 5.0 5.1 Ener RA, Meglathery SB, Van Decker WA, Gallagher RM (2003). "Serotonin syndrome and other serotonergic disorders". Pain Med. 4 (1): 63–74. PMID 12873279.
  6. 6.0 6.1 Larach MG, Gronert GA, Allen GC, Brandom BW, Lehman EB (2010). "Clinical presentation, treatment, and complications of malignant hyperthermia in North America from 1987 to 2006". Anesth. Analg. 110 (2): 498–507. doi:10.1213/ANE.0b013e3181c6b9b2. PMID 20081135.
  7. Bouchama A, Knochel JP (2002). "Heat stroke". N. Engl. J. Med. 346 (25): 1978–88. doi:10.1056/NEJMra011089. PMID 12075060.
  8. O'Connor FG, Casa DJ, Bergeron MF, Carter R, Deuster P, Heled Y, Kark J, Leon L, McDermott B, O'Brien K, Roberts WO, Sawka M (2010). "American College of Sports Medicine Roundtable on exertional heat stroke--return to duty/return to play: conference proceedings". Curr Sports Med Rep. 9 (5): 314–21. doi:10.1249/JSR.0b013e3181f1d183. PMID 20827100.