Differentials
Shock liver
SIGNS / SYMPTOMS
Shock liver occurs in the setting of sustained hypotension or low-flow state in the liver, which is unusual in acetaminophen overdose.
INVESTIGATIONS
Serum acetaminophen level will be negative. However, this is not a definitive differentiating test. By the time liver failure develops, it would be unlikely for the acetaminophen level to be detectable.
Acute hepatitis A
SIGNS / SYMPTOMS
There may be a history of travel to an endemic region, foodborne outbreak, close contact with an infected person, or men who have sex with men.
INVESTIGATIONS
Hepatitis A IgM positive.
Acute hepatitis B
SIGNS / SYMPTOMS
There may be a history of travel to an endemic region, intravenous drug use, contact with an infected person, or men who have sex with men.
INVESTIGATIONS
Hepatitis B core antigen positive.
Hepatitis B surface antigen will be positive 2 to 10 weeks after exposure.
Other hepatotoxins
SIGNS / SYMPTOMS
An important differentiating factor is an exposure history such as exposure to mushrooms (e.g., Amanita phalloides) or herbal medicines (e.g., cascara, chaparral, comfrey, kava, ma-huang).
Drugs and other exposures include anesthetic agents (e.g., halothane), industrial chemicals (e.g., carbon tetrachloride, trichloroethylene, paraquat), ACE inhibitors, anabolic steroids, aspirin, calcium-channel blockers, ibuprofen, isoniazid, ketoconazole, methotrexate, naproxen, phenytoin, statins, or valproic acid.
INVESTIGATIONS
Serum acetaminophen level will be negative. However, this is not a definitive differentiating test. By the time liver failure develops, it would be unlikely for the acetaminophen level to be detectable.
Mononucleosis
SIGNS / SYMPTOMS
Presents with fever, pharyngitis, adenopathy, and fatigue.
INVESTIGATIONS
Atypical lymphocytosis, elevated aminotransferases, positive heterophile antibodies ("Monospot").
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