322: A Fatal Case of Acetaminophen-Induced Liver Failure due to COVID-19 ARDS

Abstract

INTRODUCTION: Patients with severe acetaminophen toxicity can have fulminant hepatic failure and should be referred early to liver transplant center We present a case of acetaminophen toxicity who could not be transferred due to hypoxia and shock from severe COVID-acute respiratory distress syndrome (ARDS) METHODS: A 43-year-old male with history of HIV, compliant with antiretroviral therapy (most recent CD4 of 686 cells/mcL), was admitted for hypoxia and chills, with concern for COVID-19 based on chest x-ray Per family, he consumed an unknown amount of Tylenol due to persistent fevers Shortly after admission, he became acutely encephalopathic, had a generalized seizure and was transferred to ICU post-intubation Initial lab work showed acetaminophen level 158 ug/mL, alanine aminotransferase and aspartate aminotransferase 1748 and >4500 units/L, respectively Given patient's grade IV encephalopathy, INR 5 0, creatinine 3 0 mg/dL, severe acidosis with pH 6 75 and lactate 18 5 mmol/L, he met criteria for emergent transfer to liver transplant center per King's College Criteria, pending hemodynamic stability Acetaminophen toxicity was treated with triple therapy of high dose N-acetylcysteine (NAC), fomepizole and emergent hemodialysis Due to concern for cerebral edema secondary to hyperammonemia (423 umol/L), patient was considered but too unstable for intracranial pressure (ICP) monitoring He was medically managed with hyperventilation, midazolam drip, hypertonic saline and blood products for coagulopathy Testing returned positive for SARS-CoV-2 and severe COVID-ARDS was managed with lung protective strategies, prone positioning, neuromuscular blockade and dexamethasone Unfortunately, he continued to decompensate with worsening hypoxemia, bradycardia, multiorgan failure and expired within 48 hours RESULTS: This case highlights that COVID-19 patients with persistent fevers and myalgias should be warned against excessive acetaminophen given potential for toxicity and liver failure, possibly inhibited from receiving life-saving therapy due to COVID-ARDS Furthermore, discussions need to be held amongst critical care and transplant teams as to how to approach emergent solid-organ transplant evaluations in COVID patients given risk of initiating necessary peritransplant immunosuppression