Mark A. Crislip, MD

Disclosures

June 14, 2021

The patient, a methamphetamine user, is found in a parking lot, rolling on the ground, completely disoriented.

Transported to the ER, he is febrile to 102, hypotensive, and in mild MOSF. His WBC is 42,000.

The examination is negative for infection. Standard workup is negative for infection; clear CXR, normal CT of chest/abdomen and pelvis. The panscan in the donut of truth is standard. Blood cultures are negative at 24 hours, so they call me.

I find nothing and he had defervesced and improved with fluids and on antibiotics. His WBC had dropped to 38,000.

The one thing I didn’t mention is that this occurred on the hottest day of the year, at least so far. It was 90 degrees out. Fahrenheit, not centigrade. Global warming isn’t that bad. Yet.

You people in Phoenix or the South may poo-poo that 90 isn’t all that hot, but we in the Great Pacific NW do not have to deal with heat. I recently saw an article about the pros and cons of moving to Portland. One of the cons was that air conditioning is not standard in housing. Yep. That’s gonna change.

What kind of infection can cause this kind of leukocytosis with a non-focal exam and studies? Meningococcus and S. pyogenes in my experience, but he isn’t sick enough.

So, I wondered, heat stroke?

He is homeless with mental illness, so access to water and food is a challenge. So, he could have been volume short, aka dehydrated.

So I Googled it.

Meth both mimics and increases the risk for heat stroke:

Death as a consequence of methamphetamine can occur in one of three ways: heart attack, heat stroke, or suicide.

and

Four workers who died of heat stroke had a documented history of alcohol abuse or high-risk drinking. In three other heat stroke fatalities, methamphetamine was detected in postmortem toxicology tests.

And while meth can cause a leukocytosis, it is more in the 10,000 range.

But.

Heatstroke can cause a leukemoid reaction. And this drives me nuts. When I saw the consult and did the search, I found two cases of heat stroke with a WBC in the 30,000 range. Can I find them now? No. Am I using the same search criteria? Yes. This happens all the time. The Google search at one moment leads to different results at another.

Oh, wait. Here it is. From UpToDate:

Laboratory studies may reveal coagulopathy, acute kidney injury (acute renal failure), acute hepatic necrosis, and a leukocytosis as high as 30,000 to 40,000/mm³.

Like this patient.

A perfect storm for heat stroke: a hot day in a heat intolerant Oregonian with little access to water and a meth habit. And a leukemoid reaction as a consequence.

He improved with supportive care.

Rationalization

Richards JR, Farias VF, Clingan CS. Association of leukocytosis with amphetamine and cocaine use. ScientificWorldJournal. 2014 Jan 22;2014:207651. Source

Tustin, Aaron W. MD, MPH; Cannon, Dawn L. MD, MS; Arbury, Sheila B. RN, MPH; Thomas, Richard J. MD, MPH; Hodgson, Michael J. MD, MPH Risk Factors for Heat-Related Illness in U.S. Workers, Journal of Occupational and Environmental Medicine: August 2018 - Volume 60 - Issue 8 - p e383-e Source

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About Dr Mark Crislip
Mark A. Crislip, MD, has been practicing infectious diseases in Portland, Oregon, since 1990. He is nobody from nowhere but has an enormous ego that leads him to think someone might care about what he has to say about infectious diseases. He has been blogging on the most endlessly fascinating specialty in all of medicine since 2008 and has yet to run out of material. Or perhaps he is just a slow learner. His multimedia empire is at edgydoc.com.

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