PED4 Unsuspected acetaminophen toxicity in a 58-day-old infant. (Pediatrics and Adolescent Medicine).

PED4 UNSUSPECTED ACETAMINOPHEN TOXICITY IN A 58-DAY-OLD INFANT. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond.

Acetaminophen is the most common medication for relief of fever in young infants. Although it has a large therapeutic index, acetaminophen has recognized toxic effects, primarily hepatic, when administered in single doses exceeding 140 mg/kg. However, acetaminophen toxicity has been increasingly recognized to be associated with multiple dosing. A 58-day-old girl was brought to the ED with a 2-day history of fever, decreased appetite, and irritability. She was evaluated the day before and sent home after a normal CBC and CXR and told to give acetaminophen for fever. Her birth history and medical history were unremarkable. Her medication included acetaminophen 80 mg every 4 hours. She was admitted to the hospital in severe dehydration. She required a saphenous cutdown to initiate fluids. After obtaining initial labs, she was transferred to our facility. She had a temperature of 38.8[degrees]C, heart rate 150/min, respiratory rate 30/min, and weight 4.9 kg. Her physical examination was remarkable for lethargy, a systolic flow murmur, hepatomegaly, and dry mucous membranes, with a capillary refill of 3 seconds. Her WBC was 18,300/[mm.sup.3] with 57% neutrophils and 6% band forms. Her hemoglobin was 7.7 g/dL and platelets 234,000/[mm.sup.3]. Her electrolytes revealed a bicarbonate of 9 mEq/L and a glucose of 6 mg/dL. Her alkaline phosphatase was 352 U/L, AST 1,070 U/L, and ALT 490 U/L. Her PT was 37.6 sec, INR 3.4, and PTT 42 sec. Her chest radiograph was normal. The patient was intubated and admitted to the PICU. Due to the liver failure, an acetaminophen level was sent and it was 287 mg/mL. During the hospitalization, she was given N-acetylcysteine (NAC), blood transfusions, lactulose, fresh frozen plasma, and portagen feeding. She did remarkably well and was discharged in stable condition in 10 days. Acetaminophen toxicity may be difficult to diagnose in young infants when suspicion for this entity is low. In addition, initial symptoms are nonspecific, such as vomiting, malaise, and diaphoresis. This is typically f ollowed by an asymptomatic period. Within a few hours, severe overdoses manifest with elevated hepatic transaminases. Fortunately, most patients have normal hepatic transaminases within 14 days. Treatment of severe ingestions is with NAC and supportive therapy aimed at the hepatic failure.