Case history

Case history #1

A 20-year-old woman presents 3 hours after ingesting two packets of acetaminophen tablets following an argument with her boyfriend. She is asymptomatic.

Case history #2

A 38-year-old woman presents with nausea and pain from a tooth abscess. On further questioning she states that she has been ingesting small handfuls of acetaminophen-containing pills every few hours over the previous 2 to 3 days.

Other presentations

Acute liver injury or fulminant hepatic failure of undetermined etiology may occur if an acetaminophen overdose has been taken several days earlier.

It is rare for patients to present with isolated renal injury (<1% of cases); however, renal injury is common in patients with significant hepatotoxicity and hepatic failure, occurring in 25% and 53% of cases, respectively.[6][7][8]

Coma and severe metabolic acidosis is uncommon but well-described following acute massive acetaminophen overdose (serum concentration >800 micrograms/mL) and may precede the development of hepatotoxicity.[9] Recent studies suggest that intestinal enterocyte damage might explain markedly slowed drug absorption and hyperlactatemia seen after large overdoses, as signaled by large and statistically significant elevations in the novel biomarker intestinal fatty acid binding protein (IAFP). Because IAFP correlates with both acetaminophen and lactate concentrations, intestinal toxicity may be dose dependent.[10] Additionally, coma and respiratory depression can occur in the absence of massive overdose when a combination formulation of acetaminophen and an opioid or other central nervous system depressant has been ingested.

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