Fulminant Liver Failure: Presumed Tylenol Overdose
Patient Presentation
K.B., 16-year-old female, presented to the ER with her mother confused and combative. Mother stated that the girl had been upstairs in her room and came downstairs in a confused and enraged state. Mother said K.B. has battled depression since her parents divorced a couple years ago and she also recently broke up with a serious boyfriend. In addition to K.B.’s altered level of consciousness, she was actively vomiting and her skin was markedly jaundiced with yellow sclera. K.B. became violent with the ER staff and was consequently sedated and restrained while labs were sent. LFTs were noted to be elevated and K.B. was electively intubated.
Differential List
Shock Liver, Acute Hepatitis A, Acute Hepatitis B, Ingested Hepatoxins, Autoimmune disease, Metabolic Disorder
Diagnosis
K.B. was admitted to the PICU intubated and sedated. Upon admission, she was noted to have runs of bigeminy/trigeminy and was given electrolyte replacements to resolve PVCs. Arterial and central lines were established. She was immediately transported for a head CT which showed diffuse cerebral edema. Lab values: Creatinine: 1.13, BUN: 20, Direct Bili: 4.4, Total Bili: 7.8, Alk Phos: 158, serum albumin: 2.7, T. Protein: 4.9, AST: 635, ALT: 2,516, Phos: 1.8, serum ammonia: 112, serum amylase: 49, serum lipase: 587, serum acetaminophen: WNL. The father was asked to explore her room for any drugs and he brought back an empty bottle of Tylenol® in addition to a bottle of Claritin®. Parents were also asked if pt was known to take any illicit drugs, including cocaine, but parents were not certain. Pt was officially diagnosed with hepatoxin ingestion, presumably a Tylenol® overdose with the time of ingestion unknown.
Treatment
Pt remained ventilated and was started on a mannitol drip to decrease brain swelling. Pt was listed Status 1-A for an isolated liver transplant. A liver biopsy was sent as part of the transplant protocol which showed fulminant hepatitis and moderate active hepatitis with multifocal zonal necrosis. Pt continued to required electrolyte replacements to resolve persistent PVCs.
Outcome
After 24hrs in the PICU, pt underwent a second head CT which showed markedly resolved cerebral edema. Pt remained disoriented but her violent behavior had abated. Within 3 days, pt was extubated and had a depressed demeanor but became increasingly alert and oriented. Due to her marked improvement, pt was removed from the transplant list and within 10 days was discharged from the PICU to a psych facility for inpatient treatment. Notable labs upon discharge: AST: 34, ALT: 245, Direct Bili: 2, Total Bili: 2.7.