Severe hepatotoxicity after therapeutic doses of acetaminophen.
BACKGROUND
Acetaminophen overdose is a frequent cause of acute liver failure. Controversy exists over the rare association of severe hepatotoxicity or acute liver failure with therapeutic doses of acetaminophen.


METHODS
A 45-year-old white man weighing 85 kg with asymptomatic HIV, hepatitis B virus, and hepatitis C virus (HCV) infection presented with signs of severe hepatotoxicity: aspartate aminotransferase (AST), 8,581 IU/L; alanine aminotransferase (ALT), 5,433 IU/L; L-lactate dehydrogenase, 13,641 IU/L; and prothrombin international normalized ratio, 2.15. He reported taking acetaminophen 1,000 mg QID for the previous 4 days and 1,000 mg that morning because of a febrile illness. Immediate administration of continuous IV N-acetylcysteine 150 mg/kg for the first 90 minutes and then 50 mg/kg q4h for the next 3 days was followed by clinical improvement and a rapid decrease in AST and ALT. AST levels decreased from 8,581 to 42 IU/L within 11 days. Several potential risk factors for acetaminophen hepatotoxicity (ie, chronic alcohol, tobacco, and opiate consumption, malnutrition, illness-induced starvation, HIV infection, and HCV infection) were present in this patient.


CONCLUSIONS
This patient with multiple risk factors and severe hepatotoxicity after therapeutic dosage of acetaminophen was successfully treated with N-acetylcysteine.
Moling
Oswald
O
Division of Infectious Diseases, Ospedale Generale, Bolzano, Italy. molosw@hotmail.com
Cairon
Elena
E
Rimenti
Giovanni
G
Rizza
Francesco
F
Pristerá
Raffaele
R
Mian
Peter
P
D000082:Acetaminophen / Q000009:adverse effects* / Q000097:blood / Q000627:therapeutic use; D000111:Acetylcysteine / Q000627:therapeutic use*; D000428:Alcohol Drinking; D018712:Analgesics, Non-Narcotic / Q000009:adverse effects* / Q000097:blood / Q000627:therapeutic use; D056486:Chemical and Drug Induced Liver Injury / Q000209:etiology*; D006679:HIV Seropositivity / Q000821:virology; D006509:Hepatitis B / Q000821:virology; D006526:Hepatitis C / Q000821:virology*; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D015819:Substance Abuse, Intravenous
D018712:Analgesics, Non-Narcotic; D000082:Acetaminophen; D000111:Acetylcysteine