Grand Rounds

Acute Liver Failure due to acetaminophen toxicity - How to treat?

Ira Shah, Parth Gada
Medical Sciences Department, Pediatric Oncall, Mumbai, India.

Address for Correspondence: Dr Ira Shah, 1/B Saguna, 271/B St Francis Road, Vile Parle (W), Mumbai 400056. India.

Clinical Problem:
A 21 months old boy presented with fever, cough, cold for 4 days, drowsiness for 2 days and one episode of convulsion. He had been treated with oral paracetamol for the initial 2 days of fever every 4 hourly with intake of 150 mg/kg/day. There was no other drug ingestion. There was no jaundice. He was a full term delivery with birth weight of 3.5 kg. He was immunized till date and had normal milestones. On examination, he was comatose with Glasgow coma scale of 4/15. He had pallor, rickets and hepatomegaly. Other systems were normal. Investigations showed hemoglobin 10.2 gm/dl, white cell count 2,600/cumm (32% polymorphs, 62% lymphocyte), platelets 19,400/cumm, bilirubin 1.2 mg/dl, SGOT 1645 IU/L, SGPT 2190 IU/L, serum albumin 2.7 gm/dl, prothrombin time 11.5 sec, partial thromboplastin time 73 sec and ammonia 170 mg/dl with no metabolic acidosis. His ultrasound showed moderate hepatomegaly. HIV ELISA, leptospira IgM, HBsAg, Hepatitis C antibody, Hepatitis A IgM ELISA were negative. His autoimmune markers for liver disease were negative and serum alpha fetoprotein was normal. He was treated with N-acetyl cysteine, fresh frozen plasma, lactulose and diazepam for seizures. He responded to above measures and recovered after 72 hours. Serum paracetamol levels could not be done in the child.

How should this child be treated?

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ISPPD 2018
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