Undifferentiated Altered Mental Status: A Late Presentation of Toxic Acetaminophen Ingestion

Altered mental status is a common undifferentiated presentation in the emergency department. We describe a case of acetaminophen-induced acute liver failure that was diagnosed and treated prior to obtaining definitive historical or laboratory information about the etiology. The physical exam finding of scleral icterus in this case was a key element to rapid identification and treatment of this life-threatening condition. A discussion of appropriate N-acetylcysteine treatment for acute liver failure and acetaminophen intoxication is included.

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A Case of Exertional Heat Stroke Complicated by Hypoxic Hepatitis

Case Reports in Emergency Medicine ◽

10.1155/2020/8724285 ◽

2020 ◽

Vol 2020 ◽

pp. 1-4

Author(s):

Bertram K. Woitok ◽

Shawki Bahmad ◽

Gregor Lindner

Keyword(s):

Supportive Care ◽

Liver Failure ◽

Acute Liver Failure ◽

Multiorgan Failure ◽

Heat Stroke ◽

Exertional Heat Stroke ◽

Hypoxic Hepatitis ◽

Threatening Condition ◽

Life Threatening ◽

Delayed Referral

Background.Exertional heat stroke is a life-threatening condition often complicated by multiorgan failure. We hereby present a case of a 25-year-old male presenting with syncope after a 10 km run in 28°C outside temperature who developed acute liver failure. Case Presentation. Initial temperature was found to be 41.1°C, and cooling measures were rapidly applied. He suffered from acute renal failure and rhabdomyolysis and proceeded to acute liver failure (ASAT 6100 U/l and ALAT 6561 U/l) due to hypoxic hepatitis on day 3. He did not meet criteria for emergency liver transplantation and recovered on supportive care. Conclusions. Acute liver failure due to heat stroke is a life-threatening condition with often delayed onset, which nevertheless resolves on supportive care in the majority of cases; thus, a delayed referral to transplant seems to be reasonable.

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Plasma Exchange as a Rescue Therapy for Acute Liver Failure

JOURNAL FOR CLINICAL AND DIAGNOSTIC RESEARCH ◽

10.7860/jcdr/2021/49865.15371 ◽

2021 ◽

Author(s):

Nupur B Patel ◽

Anand Sharma ◽

Itish Patnaik ◽

Ashok Kumar

Keyword(s):

Liver Failure ◽

Acute Liver Failure ◽

Plasma Exchange ◽

Resource Constraints ◽

Rescue Therapy ◽

Therapeutic Option ◽

Liver Function Tests ◽

Threatening Condition ◽

Life Threatening

Acute Liver Failure (ALF) is a life-threatening condition and often necessitates Liver Transplantation (LT). However, LT is not available to most patients in developing countries due to resource constraints. Here, authors presents a case of 30-year-old female with ALF and fulfilled the criteria for LT. The aetiology of ALF could not be diagnosed in her. Due to the lack of LT facilities, she was offered plasma exchange as a therapeutic option, which resulted in improvement in sensorium and Liver Function Tests (LFT) {bilirubin, International Normalised Ratio (INR), Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT)} over a period of two weeks. She was discharged and was doing well during follow-up. Plasma exchange is a less studied but potential treatment option for ALF when LT is not feasible.

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Case Report: Pediatric Recurrent Acute Liver Failure Caused by Neuroblastoma Amplified Sequence (NBAS) Gene Mutations

Frontiers in Pediatrics ◽

10.3389/fped.2020.607005 ◽

2021 ◽

Vol 8 ◽

Author(s):

Bingxin Jiang ◽

Fangfei Xiao ◽

Xiaolu Li ◽

Yongmei Xiao ◽

Yizhong Wang ◽

...

Keyword(s):

Liver Failure ◽

Acute Liver Failure ◽

Gene Mutations ◽

Kidney Injury ◽

Compound Heterozygote ◽

Healthy Children ◽

Whole Exome ◽

Threatening Condition ◽

Chinese Girl ◽

Life Threatening

Acute liver failure (ALF) in childhood is a rapidly progressive, potentially life-threatening condition that occurs in previously healthy children of all ages. However, the etiology of ~50% of cases with pediatric ALF remains unknown. We herein report a 4-year-old Chinese girl with recurrent ALF (RALF) due to a mutation in the neuroblastoma amplified sequence (NBAS) gene. The patient had suffered from multiple episodes of fever-related ALF since early childhood. She had also suffered from acute kidney injury, hypertension, mild pulmonary hypertension, pleural effusion, and hypothyroidism. A novel compound heterozygote mutation, c.3596G> A (p.C1199Y)/ex.9del (p.216-248del), in the NBAS gene was identified by whole-exome sequencing (WES). The missense mutation c.3596G> A (p. C1199Y) was inherited from her father, and ex.9del (p.216-248del) was inherited from her mother. The patient was managed with intensive treatments, such as renal replacement therapy (CRRT), intravenous antibiotics, and glucose infusion, and was discharged after full recovery. We identified a novel compound heterozygote mutation in the NBAS gene that caused fever-related RALF in a Chinese child, which further expands the mutational spectrum of NBAS.

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Porcine model characterizing various parameters assessing the outcome after acetaminophen intoxication induced acute liver failure

World Journal of Gastroenterology ◽

10.3748/wjg.v23.i9.1576 ◽

2017 ◽

Vol 23 (9) ◽

pp. 1576 ◽

Cited By ~ 1

Author(s):

Karolin Thiel ◽

Wilfried Klingert ◽

Kathrin Klingert ◽

Matthias H Morgalla ◽

Martin U Schuhmann ◽

...

Keyword(s):

Liver Failure ◽

Acute Liver Failure ◽

Porcine Model ◽

Acetaminophen Intoxication

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Life‐threatening acute liver failure and myocarditis needing extracorporeal membrane oxygenation: Could it be therapeutic misadventure with paracetamol?

Journal of Paediatrics and Child Health ◽

10.1111/jpc.15865 ◽

2021 ◽

Author(s):

Nitin Mohan ◽

Nitesh Singhal ◽

Michael O Stormon ◽

Philip N Britton ◽

Matthew Liava'a ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Liver Failure ◽

Acute Liver Failure ◽

Membrane Oxygenation ◽

Life Threatening

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Altered Mental Status in the Emergency Department

Seminars in Neurology ◽

10.1055/s-0038-1677035 ◽

2019 ◽

Vol 39 (01) ◽

pp. 005-019 ◽

Cited By ~ 4

Author(s):

Austin Smith ◽

Jin Han

Keyword(s):

Emergency Department ◽

Mental Status ◽

Altered Mental Status ◽

Detailed History ◽

Radiographic Testing ◽

Life Threatening ◽

Secondary Survey ◽

Acute Changes ◽

Department Evaluation ◽

The Brain

AbstractAltered mental status is an umbrella term that covers a broad spectrum of disease processes that vary greatly in chronicity and severity. Causes can be a primary neurologic insult or a result of a systemic illness resulting in end-organ dysfunction of the brain. Acute changes in mental status are more likely than chronic changes to be immediately life-threatening and are therefore the focus of this review. Given the potential time-sensitive nature, acute changes in mental status must be addressed immediately and with urgency. We recommend a primary survey followed by a secondary survey with special attention to immediate life-threatening reversible causes. We then recommend a systems-based approach searching for any other life-threatening or reversible causes. Because the differential for altered mental status is broad, a comprehensive emergency department evaluation including a detailed history and physical exam as well as laboratory and radiographic testing is needed.

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Apoptosis versus necrosis rate as a predictor in acute liver failure following acetaminophen intoxication compared with acute-on-chronic liver failure

Liver International ◽

10.1111/j.1478-3231.2007.01566.x ◽

2007 ◽

Vol 0 (0) ◽

pp. 070901081846006-??? ◽

Cited By ~ 4

Author(s):

Lars P. Bechmann ◽

Guido Marquitan ◽

Christoph Jochum ◽

Fuat Saner ◽

Guido Gerken ◽

...

Keyword(s):

Liver Failure ◽

Acute Liver Failure ◽

Chronic Liver ◽

Chronic Liver Failure ◽

Necrosis Rate ◽

Acetaminophen Intoxication

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ACTION OF VITAMIN E ON EXPERIMENTAL SEVERE ACUTE LIVER FAILURE

Arquivos de Gastroenterologia ◽

10.1590/s0004-2803.201700000-03 ◽

2017 ◽

Vol 54 (2) ◽

pp. 123-129 ◽

Cited By ~ 6

Author(s):

Fabiano Moraes MIGUEL ◽

Elizângela Gonçalves SCHEMITT ◽

Josieli Raskopf COLARES ◽

Renata Minuzzo HARTMANN ◽

Maria Isabel MORGAN-MARTINS ◽

...

Keyword(s):

Vitamin E ◽

Liver Failure ◽

Acute Liver Failure ◽

Clinical Syndrome ◽

Control Group ◽

Activity Levels ◽

Liver Functions ◽

Life Threatening ◽

Hepatocyte Necrosis ◽

The One

ABSTRACT BACKGROUND Severe Acute Liver Failure (ALF) is a life-threatening clinical syndrome characterized by hepatocyte necrosis, loss of hepatic architecture, and impairment of liver functions. One of the main causes of ALF is hepatotoxicity from chemical agents, which damage hepatocytes and result in increase of reactive oxygen species. The vitamin E isoform is the one with the strongest biological antioxidant activity. OBJECTIVE To evaluate the antioxidant effect of vitamin E in this ALF model. METHODS We used 56 rats (mean weight of 300 g) divided into eight groups, four groups assessed at 24 hours and 4 assessed at 48 hours after induction: control group (CO); Vitamin E (Vit. E); Thioacetamide (TAA) and Thioacetamide + Vitamina E (TAA+Vit.E). Rats were submitted to injections of thioacetamide (400 mg/kg i.p.) at baseline and 8 hours later. Vitamin E (100 mg/kg ip) was administered 30 minutes after the second dose of thioacetamide. The 48-hour group rats received two additional doses of vitamin E (24h and 36h). At 24h or 48 hours after the administration of the first dose of TAA, rats were weighed and anesthetized and their blood sampled for evaluation of liver integrity through enzymes aspartate aminotransferase (AST) and alanine aminotransferase (ALT). Liver tissue was sampled for assessment of lipid peroxidation (LPO) by the technique TBARS, antioxidant enzymes SOD, CAT, GPx and GST activity, levels of the NO 2 /NO 3 and histology by H&E in two times. The results were expressed as mean ± standard deviation and statistically analyzed by ANOVA followed by Student-Newman-Keuls, with P <0.05 considered as significant. RESULTS After treatment with vitamin E, we observed a reduction in liver enzymes AST (U/L) (101.32±19.45 in 24 hours and 97.85±29.65 in 48 hours) related to the TAA group (469.56± 0.69 in 24 hours and 598.23±55.45 in 48 hours) and ALT (U/L) (76.59±8.56 in 24 hours and 68.47±6.49 in 48 hours) compared to the TAA group (312.21±10.23 in 24 hours and 359.15±17.58 in 48 hours). There was a reduction of LPO (nmol/mg Prot) in the TAA+Vit.E group (0.77±0.07 in 24 hours and 0.95±0.08 in 48 hours) compared to the TAA group (1.50±0.07 in 24 hours e 1.65±0.16 in 48 hours). SOD decreased in the TAA+Vit.E group (49.48±9.47 in 24 hours and 62.45±18, 47 in 48 hours), related to the TAA group (98.46±15.48 in 24 hours and 154.13±21.46 in 48 hours), as well as GST (nmol/min/mg Prot) in the TAA+Vit.E group (350.57±36.93 in 24 hours and 453.29±13.84 in 48 hours) compared to the TAA group (561.57±64.56 in 24 hours and 673.43±38.13 in 48 hours). There was an increase in CAT (pmol/min/mg Prot) in the TAA+Vit.E group (3.40±0.44 in 24 hours and 3.0±0.35 in 48 hours) compared to the TAA group (1.65±0.21 in 24 hours and 1.86±0.42 in 48 hours). The GPx (nmol/min/mg Prot) increased in 24 hours in the TAA+Vit.E group (1.01±0.16) compared to the TAA group (0.41±0.04) and decreased in 48 hours (1.19±0.17) compared to the TAA group (1.76±0.21). There was a reduction in NO2/NO3 (mmol/L) levels in the TAA+Vit.E group (31.47±4.26 in 24 hours and 38.93±5.20 in 48 hours) compared to the TAA group (49.37±5.12 in 24 hours and 53.53±5.97 in 48 hours). The histopathological evaluation showed a decrease in liver injury (necrosis and inflammation) in both studied times. CONCLUSION These results suggest that vitamin E was able to protect the liver from lesions caused by thioacetamide.

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Aggressive Treatment of Life-Threatening Hypophosphatemia During Recovery From Fulminant Hepatic Failure: A Case Report

Journal of Intensive Care Medicine ◽

10.1177/0885066617738715 ◽

2017 ◽

Vol 33 (6) ◽

pp. 375-379 ◽

Cited By ~ 3

Author(s):

Brittany D. Bissell ◽

Jason E. Davis ◽

Alexander H. Flannery ◽

David A. Adkins ◽

Melissa L. Thompson Bastin

Keyword(s):

Liver Failure ◽

Continuous Infusion ◽

Liver Enzymes ◽

High Dose ◽

Fulminant Liver Failure ◽

Aggressive Approach ◽

Hepatocyte Regeneration ◽

Threatening Condition ◽

Life Threatening ◽

Safe Approach

Acute liver failure secondary to acetaminophen overdose can be a life-threatening condition, characterized by severe electrolyte derangements. Hepatocyte regeneration is associated with phosphorous utilization and is a known complication of liver recovery following injury. We report the case of profound, life-threatening hypophosphatemia following recovery from acute fulminant liver failure. As the liver enzymes normalized, serum phosphorous levels plummeted. Our patient required an aggressive, individualized phosphorus replacement regimen, which resulted in a continuous infusion of intravenous (IV) sodium phosphate, titrated to a maximum rate of 30 mmol/h or 0.5 mmol/kg/h. The patient required over 400 mmol of total IV and oral phosphorous over the course of 48 hours. An aggressive approach to phosphorous replacement was done safely and effectively. Traditional replacement protocols are not adequate to sustain patients with this degree of hypophosphatemia. This is the first report to utilize a continuous infusion of phosphate with a maximum reported rate (0.5 mmol/kg/h). Our report summarizes a novel and safe approach for clinicians to maximally support these patients through high-dose, continuous infusion phosphorous administration.

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