PROFOUND WEAKNESS AFTER AN ARCTIC EXPEDITION

HISTORY - 29 y/o previously healthy Norwegian male presented with profound weakness and palpitations 36 hours after he and a fellow expeditioner successfully completed the first unsupported Arctic ski trek. The expedition consisted of a 109-day mission traversing 1,914 km from Russia through the North Pole to Canada. On the ice, he consumed a high fat, high calorie daily ration of 6,000 kcal/d. Some food ingested during the final 19 days of the trek may have been contaminated by fuel, which spilled onto the limited rations. Only pre-packed food rations were ingested during the trek. No significant alcohol or drug history was noted. PHYSICAL EXAM- Ht- 188 cm, wt- 89.1kg (down 25.4 kg from pre-expedition wt of 114.5 kg), BP- 155/70 supine, 126/70 standing, pulse- 52 supine, 55 standing, normothermic, General- emaciated white male in mild distress, alert and oriented, Lungs- clear, CV- occasional premature beats, no murmurs or gallops, Abdomentender hepatomegaly with liver edge 2 cm below right costal margin, no splenomegaly, masses, or ascites, GU/Rectal-normal, Extremities-no edema or frostbite injury, decreased sensation to pinprick over fingers and toes, hands pale appearing, Neurologic- normal, gait slowed with difficulty walking up a 5% grade, muscle strength 4/5 throughout, no muscle tenderness or fasciculations, reflexes normal. DIFFERENTIAL DIAGNOSIS - Hepatic- 1) hepatitis- viral 2) toxic hepatic necrosis from hydrocarbon fuel ingestion 3) acute fatty liver secondary to high fat diet Neurologic-peripheral neuropathy: 1) toxicity from hydrocarbon ingestion 2) cold-induced 3) thiamine deficiency Metabolic- protein- calorie malnutrition TESTS AND RESULTS- Chemistries normal except for potassium-3.4 (nl 3.5–5.3), chloride-107 (nl 98–106), total protein-5.4 (nl 6.2–8.0), albumin-2.8 (nl 3.5–5.0), AST-142 (nl 15–37), ALT-149 (nl 30–65), LDH- 232 (nl 100–200). Cardiac enzymes, CBC, PT/PTT, hepatitis panel, blood cultures, monospot, and TFT-all normal, drug screen- negative, EKG- normal sinus rhythm, diffuse non-specific T wave abnormalities, CXR- normal, CT Scan of Abdomen- mild to moderate hepatomegaly with increased liver density, DEXA - 5.9% body fat FINAL/WORKING DIAGNOSIS- Acute hepatitis secondary to inadvertent fuel ingestion Peripheral neuropathy- hydrocarbon toxicity vs. cold-induced vs. nutritional Protein-calorie malnutrition with hypoalbuminemia TREATMENT - Phone consultation with Denver Poison Control Center, no antidote available this late after hydrocarbon ingestion. Refeeding, thiamine, folate, and vitamin repletion. I.V. hydration and electrolyte replacement begun. Supportive care given. Follow-up care requested with gastroenterologist and neurologist upon return to Norway for resolution of liver function abnormalities and neuropathy.

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