title: Heatstroke during endurance exercise: is there evidence for excessive endothermy?
abstract: OBJECTIVE
  Five of 28,753 cyclists participating in an annual 109-km bicycle race died, four within 24 h of the race and the fifth 17 d later. All five deaths were reported to be the consequence of exertional heatstroke. One runner of 6874 participating in an annual 56-km ultramarathon developed heatstroke and required active cooling for 10 h to achieve normothermia. The purpose of this article was to postulate (i) why only 6 of 35,627 athletes were hospitalized for heatstroke in these races, (ii) if exercise alone could have elevated their body temperatures sufficiently to cause heatstroke, and (iii) why the runner required such prolonged cooling.
  
  
  METHODS
  Clinical and autopsy data are presented for three of the cyclists and the runner for whom access to this information was granted. Calculations were made to predict the work rates necessary to produce their measured rectal temperatures.
  
  
  RESULTS
  The rectal temperatures of two of the cyclists were 42.0 and 41.2 degrees C on hospitalization, and that of the runner was 41.8 degrees C on collapse. Standard calculations showed that in the prevailing environmental conditions and with their exercise speeds, none should have developed exertional heatstroke. The third cyclist experienced a cardiac arrest to which his elevated (rectal) temperature may have contributed.
  
  
  CONCLUSIONS
  The hyperthermic states experienced by the cases presented may have resulted from failure of their heat-losing mechanisms. Alternatively, they might have resulted from excessive endothermy, triggered by physical exertion and other unknown initiating factors. Excessive endothermy should be considered in cases of heatstroke that occur in mild to moderate environmental conditions. Furthermore, prompt initiation of cooling is crucial in all cases of suspected heatstroke.
authors.affiliation: 1UCT/MRC Research Unit for Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, SOUTH AFRICA.
authors.forename: Dale E
authors.initials: DE
authors.lastname: Rae
authors.forename: Gideon J
authors.initials: GJ
authors.lastname: Knobel
authors.forename: Theresa
authors.initials: T
authors.lastname: Mann
authors.forename: Jeroen
authors.initials: J
authors.lastname: Swart
authors.forename: Ross
authors.initials: R
authors.lastname: Tucker
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Noakes
mesh_terms: D000064:Acclimatization; D000328:Adult; D001642:Bicycling / Q000502:physiology*; D001833:Body Temperature Regulation; D016757:Death, Sudden, Cardiac / Q000209:etiology* / Q000473:pathology; D017079:Exercise Tolerance; D017809:Fatal Outcome; D018883:Heat Stroke / Q000150:complications / Q000209:etiology*; D006801:Humans; D007668:Kidney / Q000473:pathology; D008297:Male; D018482:Muscle, Skeletal / Q000473:pathology; D010807:Physical Endurance / Q000502:physiology*; D012307:Risk Factors; D012420:Running / Q000502:physiology*