Frostbite complicating therapeutic surface cooling after heat stroke

Dear Editor, We report the case of an apparently healthy young woman found unconscious in a sauna suffering from heat stroke syndrome (GCS score 3/15; core temperature 41.9 C; BP 80/60, pulse 160/min). She was immediately treated with external surface cooling, initially using towels soaked with ice packs (*20 min) followed by cold wet blankets (*40 min), applied from the lower abdomen to the proximal half of the thighs. No accessory cooling method was used. She was also administered oxygen (FiO2 100%) and a perfusion of 1,000 ml NaCl at ambient temperature. Within just about 1 h, the patient’s core temperature was actively decreased from 41.9 C (tympanic, on-site) to 38 C (rectal, ER) with immediate effects on vital parameters. Nevertheless, the following day, the patient developed within the initial cooling zone progressive skin lesions, evolving from blisters to full-thickness skin and fat necrosis, which required skin grafting 43 days after the incident (Fig. 1a, b). The diagnosis was frostbite secondary to local cooling for heat stroke syndrome treatment. Heat stroke syndrome is defined as core temperature exceeding 40 C associated with a change in mental status ranging from inappropriate behaviour or impaired judgment to delirium, epilepsy or coma [1–3]. In 20–65% of the cases, an acute circulatory failure (shock) is associated [1–3] as observed in our patient. Treatment consists mainly of therapeutic cooling and cardiovascular