Sudden Death: Is There a Human Stress Syndrome?-Reply

In Reply.—  We have investigated further the circumstances of death in the six patients in question and the detailed findings are listed in the Table.Two of the six patients had myocardial contraction bands. Additional myocardial sections from the heart of the patient with rhabdomyolysis and hyperkalemia revealed multiple foci of myocyte necrosis with lymphocytic and plasma cell infiltrates. The differential diagnosis is idiopathic myocarditis, resolving catecholamine necrosis, or shock-induced myocardial necrosis. We favor the last, as the patient survived three days after circulatory collapse.¹ Findings from the toxicology screens were negative in all six; none had prior history of cardiovascular complaints, syncope, or drug- or anesthesia-related problems.Malignant hyperthermia is associated with marked elevations of catecholamine levels, especially norepinephrine, and would be expected to induce myocardial contraction band necrosis.^2,3 It is still possible that malignant hyperthermia may have been present in some of the recruits, as susceptibility