3186 Fatal Case of Acetaminophen Toxicity in a Young Female Patient

Abstract

INTRODUCTION: Acetaminophen is the most common cause of acute liver failure (ALF) in the United States. We report a fatal case of acetaminophen overdose after both delayed presentation for treatment and transplant evaluation in a non-liver transplant academic center. CASE DESCRIPTION/METHODS: An 18-year-old woman presented to the emergency department (ED) after attempting suicide by overdosing on acetaminophen. She ingested 48 of the 500 mg tablets (24-gram total dose) 18 hours prior to arrival to the ED. Her only symptom was back pain. Her medical history was significant for depression and three prior suicide attempts by acetaminophen overdose. Her mental status declined over the next few hours to the point of becoming non-verbal and mildly drowsy. On physical exam, patient was tachycardic and had self-inflicted scars to her forearms. Initial labs were significant for white blood cell count of 22,300 cells/mm3, bicarbonate of <5 mmol/L (21-31), glucose 59 mg/dL (70-110), alkaline phosphatase 91 units/L (42-121), aspartate aminotransferase 479 units/L (5-34), alanine aminotransferase acetaminophen 228 mcg/mL (<30), PT 27 seconds (9.4-12.5 sec), INR 2.5, and ammonia 147 mcmol/L (18-72). Venous blood gas revealed pH 6.819, pCO2 29 mmHg (39-51), pO2 51 mmHg (30-50), calculated bicarbonate of 4 mmol/L, and lactate of 14 mmol/L (0.5-2.20). Table 1 highlights changes in laboratory values during admission. The patient was admitted to the ICU, started on N-acetylcysteine (NAC) and bicarbonate infusions, and had urgent renal and general gastroenterology consultations. 48 hours after admission the patient was intubated due to deteriorating mental status and seizure activity. It was suspected that she was having cerebral edema and was emergently transferred to a liver transplant center. Ultimately, she did not undergo transplant and died from complications of ALF. DISCUSSION: Acetaminophen overdose carries a high risk of ALF and mortality. Survival depends on early treatment as high doses can overwhelm liver metabolism resulting in hepatotoxicity by N-acetyl-p-benzoquinoneimine (NAPQI). Treatment from time of ingestion was delayed in this case due to the patient's delay in seeking care. Transfer to transplant center was delayed due to lack of insurance, history of multiple attempts that affected her liver transplant candidacy, and under-appreciating risk of developing ALF. This case highlights the fatal complications of acetaminophen overdose, and underscores the importance of emergent transfer to transplant center.