Death from acute liver failure due to concomitant use of propacetamol hydrochloride, cefuroxime sodium, and low molecular weight heparin calcium

Abstract

A 62-year-old male patient received propacetamol hydrochloride for analgesia, cefuroxime sodium for anti-infection, adenosine cobalamin for nutrition of nerve, and low molecular weight heparin calcium for anticoagulation for burst fracture of the third lumbar vertebra and multiple fractures of transverse process of lumbar spine caused by traffic accident. The patient′s liver function was normal before medication. He underwent the operation under general anesthesia 2 days later. Low molecular weight heparin calcium was stopped before the operation. On day 3 after the operation (on day 5 of medication), the patient developed abdominal distension and pain. The results of laboratory tests showed alanine aminotransferase (ALT) 9 315 U/L, aspartate aminotransferase (AST) 10 760 U/L, gamma glutamyltransferase (γ-GT) 47 U/L, alkaline phosphatase (ALP) 101 U/L, total bilirubin (TBil) 71.3 μmol/L, direct bilirubin (DBil) 48.5 μmol/L, and indirect bilirubin (IBil) 22.8 μmol/L. Drug-induced liver injury was considered. Propacetamol hydrochloride was discontinued and liver-protective drugs were given. The next day, the patient developed yellow staining of his sclera and whole body skin, then followed by confusion, decreased blood oxygen saturation, low blood pressure, and hypoglycemia. The results of reexamination showed ALT 5 975 U/L, AST 3 659 U/L, γ-GT 100 U/L, ALP 141 U/L, TBil 175.2 μmol/L, DBil 101.4 μmol/L, IBil 73.8 μmol/L, and prothrombin time 21.2 s. The patient was diagnosed as acute liver failure. Cefuroxime sodium and adenosine cobalamin were discontinued and symptomatic and supportive treatments such as increasing blood pressure, fluid supplement, and correction of acidosis were given. However, the patient′s condition was not improved. He was transferred to other hospital on the same day. On the 4th day, he died of multiple organ failure. Key words: Phenacetin; Cefuroxime; Heparin, low-molecular-weight; Chemical and drug induced injury; Liver failure, acute