Procalcitonin as a marker of disease severity in heatstroke
Date First Published:
July 10, 2009
Last Updated:
July 13, 2009
Report by:
Matthew Newport, Medical Student (Manchester Royal Infirmary)
Three-Part Question:
In [adult patients presenting to the ED with heat-stroke] is [procalcitonin] a [useful marker of disease severity]?
Clinical Scenario:
A 50 year old male is brought in by ambulance after a collapse. It is a hot day and the patient had been playing 5-aside football when he collapsed. In the Emergency Department he is a assessed, having a rectal temperature of 41.5C and a GCS of 4. The patient is hot and not sweating. A diagnosis of heatstroke is made. You wonder if the patient’s serum procalcitonin might be a useful indicator of disease severity.
Search Strategy:
Ovid Medline® 1950 to June Week 2 2009
Ovid Embase 1980 to 2009 Week 25
Ovid EBM Reviews- Cochrane Central Register of Controlled Trials 2nd Quarter 2009
Ovid EBM Reviews - Cochrane Database of Systematic Reviews 2nd Quarter 2009
EBSCOHost CINAHL Plus
Ovid Embase 1980 to 2009 Week 25
Ovid EBM Reviews- Cochrane Central Register of Controlled Trials 2nd Quarter 2009
Ovid EBM Reviews - Cochrane Database of Systematic Reviews 2nd Quarter 2009
EBSCOHost CINAHL Plus
Search Details:
Medline® & Embase search strategies;
1. heat stress disorder.mp. or exp Heat Stress Disorders/
2. exp Calcitonin/ or procalcitonin.mp.
3. 1 and 2
4. limit 3 to (english language and humans)
Cochrane search strategy;
1. heat stress disorder.mp. or exp Heat Stress Disorders/
2. exp Calcitonin/ or procalcitonin.mp.
3. 1 and 2
Cinahl Plus search strategy;
1. (MH "Heat Stroke") or (MH "Heat Exhaustion") AND (procalcitonin OR calcitonin)
1. heat stress disorder.mp. or exp Heat Stress Disorders/
2. exp Calcitonin/ or procalcitonin.mp.
3. 1 and 2
4. limit 3 to (english language and humans)
Cochrane search strategy;
1. heat stress disorder.mp. or exp Heat Stress Disorders/
2. exp Calcitonin/ or procalcitonin.mp.
3. 1 and 2
Cinahl Plus search strategy;
1. (MH "Heat Stroke") or (MH "Heat Exhaustion") AND (procalcitonin OR calcitonin)
Outcome:
The search returned 13 results (Medline 3, Embase 8, Cinahl 1), of which 2 were deemed to be of suitable quality for inclusion.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Is procalcitonin a marker of critical illness in heatstroke? Hausfater P., Hurtado M., Pease S., Juillien G., Lvovschi V.-E., Salehabadi S., Lidove O., Wolff M., Bernard M., Chollet-Martin S., Riou B. 2008 France | 53 patients diagnosed with heatstroke in the ED. Conducted during France’s 2003 heat wave. Serum PCT on admission and 30-day mortality investigated. | Cohort Study | 14 (26%) admitted to ICU. At 30days 24 (45%) had died. | Admission PCT +ive if >0.2 μg/l, median PCT value 0.58μg/l Median PCT in deceased group 1.4μg/l (0.16–4.71) Median PCT in surviving group 0.18μg/l (0.12–1.61) All ICU admissions had elevated PCT values. Microbiological/clinical infection not more frequent in PCT+ive group. | Variable of temperature >40.0°C significantly associated with fatality. |
| Effect of classical heatstroke on serum procalcitonin. Nylen E.S., Al Arifi A., Becker K.L., Snider Jr. R.H., Alzeer A. 1997 Saudi Arabia | 25 patients admitted for heat illness during Hajj pilgrimage, 10 of which had minor illness and no pyrexia- acted as controls. | Comparative Study | Serum PCT every 6hrs for 24hrs. Patients cooled with standard evaporative measures. | Mean serum PCT was >20x elevated in heatstroke group than controls. PCT plateau at 6hrs remained increased at 24hrs. 77% heatstroke patients survived. The 23% that died had significantly higher PCT concentration. PCT concentration >0.5μg/l at 6hrs predicted survival. |
Author Commentary:
Both exertional and classical heatstroke are characterised by neurological involvement and rectal temperature >40.6°C, requiring prompt diagnosis and immediate cooling interventions. The value of serum procalcitonin does not seem to be as a marker for mortality but does seem quite useful in indicating the severity of heatstroke. Elevated procalcitonin is seen in a range of systemic inflammatory responses syndromes, it is possible that the elevation of procalcitonin in heatstroke is linked to its synthesis along a non-septic pathway. The source of this procalcitonin requires further investigation.
Bottom Line:
Elevated serum procalcitonin is a useful marker of heatstroke disease severity. It ought to be measured where a suitable assay is readily available. The cornerstone of dealing with a heatstroke patient remains to be rectal temperature monitoring and rapid cooling techniques, with serum procalcitonin currently an aside to core management.
References:
- Hausfater P., Hurtado M., Pease S., Juillien G., Lvovschi V.-E., Salehabadi S., Lidove O., Wolff M., Bernard M., Chollet-Martin S., Riou B. . Is procalcitonin a marker of critical illness in heatstroke?
- Nylen E.S., Al Arifi A., Becker K.L., Snider Jr. R.H., Alzeer A. . Effect of classical heatstroke on serum procalcitonin.