Working Diagnosis:
Severe Exercise Induced Hyperhidrosis
Malignant Hyperthermia Susceptibility
Rhabdomyolysis

Treatment:
The patient follows a strict hydration protocol, consuming at least 4 gallons of water per day with 5 grams of sodium added per gallon. He also takes amino acid supplements and Thorne Greens Plus. Weight monitoring plays a crucial role in his routine, with a baseline morning weight of approximately 245 lbs. Before practice, he consumes 3 gallons of water, increasing his weight to 255 lbs. During practice, he drinks 64 oz of water and finishes with a post-practice weight of 235 lbs.
He maintains a non-inflammatory diet, avoids caffeine and diuretics, and has lost 30 pounds since starting this regimen. Genetic testing and a muscle biopsy have yielded no conclusive results. The patient continues to play collegiate hockey under the supervision of his neurologist and team physician, adhering strictly to the hydration protocol developed by the Korey Stringer Institute.

Outcome:
The patient remains active in his sport, following his individualized hydration strategy to prevent further episodes. His care team continues to explore genetic and neuromuscular factors to better understand his condition. Additional genetic testing is planned for further evaluation.

Author's Comments:
Exercise-induced hyperhidrosis displays a broad range of severity. The prevalence of severe cases is less documented and is primarily categorized as primary hyperhidrosis, which occurs without an underlying medical condition. The incidence rate for severe cases is difficult to determine due to the lack of standardized definitions and diagnostic criteria. The exact cause, particularly in severe instances, remains unclear. Genetic factors may play a role, as evidenced by reported family histories of excessive sweating. Environmental factors, such as temperature and humidity, can exacerbate the condition.
In this patient, there is concern about a possible genetic factor contributing to his symptoms, given his strong family and personal history of malignant hyperthermia. There is a known association between neuromuscular symptoms, such as severe muscle cramping, in patients with RYR1-related malignant hyperthermia and rhabdomyolysis. This case underscores the importance of a comprehensive multispecialty assessment to effectively manage exercise-induced hyperhidrosis.

Editor's Comments:
This case highlights the importance of multidisciplinary management in athletes with complex medical conditions such as exercise-induced hyperhidrosis and malignant hyperthermia susceptibility. It underscores the need for individualized hydration protocols and emphasizes the critical role of early recognition and treatment of rhabdomyolysis to prevent severe complications like renal failure.
In this patient, the overlap between neuromuscular symptoms and electrolyte imbalances complicates his diagnosis and management. The association between malignant hyperthermia and rhabdomyolysis is well-documented, further emphasizing the importance of multispecialty care and close monitoring.

References:
Baker LB. Sweating Rate and Sweat Sodium Concentration in Athletes: A Review of Methodology and Intra/Interindividual Variability. Sports Med. 2017 Mar;47(Suppl 1):111-128. doi: 10.1007/s40279-017-0691-5. PMID: 28332116; PMCID: PMC5371639.

Benson R A, Palin R, Holt P J E, Loftus I M. Diagnosis and management of hyperhidrosis BMJ 2013; 347 :f6800 doi:10.1136/bmj.f6800

Hashmonai, M., Cameron, A.E.P., Connery, C.P. et al. The Etiology of Primary Hyperhidrosis: A Systematic Review. Clin Auton Res 27, 379–383 (2017). https://doi.org/10.1007/s10286-017-0456-0

Kisielnicka A, Szczerkowska-Dobosz A, Purzycka-Bohdan D, Nowicki RJ. Hyperhidrosis: disease aetiology, classification and management in the light of modern treatment modalities. Postepy Dermatol Alergol. 2022 Apr;39(2):251-257. doi: 10.5114/ada.2022.115887. Epub 2022 May 9. PMID: 35645673; PMCID: PMC9131949.

Miles MP, Clarkson PM. Exercise-induced muscle pain, soreness, and cramps. The Journal of Sports Medicine and Physical Fitness. 1994 Sep;34(3):203-216. PMID: 7830383.

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