Acetaminophen-induced hepatic failure with encephalopathy in a newborn

Abstract

We report a case of oral acetaminophen toxicity in a term newborn infant successfully treated with a 20 h intravenous N-acetylcysteine infusion protocol without any adverse effects. This case report supports the use of N-acetylcysteine to treat neonatal acetaminophen toxicity and highlights the need for better education of parents regarding the appropriate use and dosage of acetaminophen in newborns. Journal of Perinatology (2007Perinatology ( ) 27, 133-135. doi:10.1038 Keywords: Neonatal acetaminophen toxicity; hepatic failure; N-acetylcysteine IntroductionAcetaminophen is an efficacious and safe analgesic used often in newborns. 1 Although it is relatively safe, acetaminophen toxicity is well documented and can lead to liver failure and even death. The risk of developing toxicity is, in general, thought to be lower in children than in adults. N-acetylcysteine (NAC) is the treatment of choice for acetaminophen overdose in older children and adults. To date, there are no documented neonatal cases of oral acetaminophen toxicity with hepatic encephalopathy. We report a case of oral acetaminophen toxicity presenting with hepatic encephalopathy and oliguric renal failure in a term newborn infant successfully treated with intravenous NAC without observable adverse effects.Case report A four day-old term male infant was brought to the emergency department after episodic emesis and decreased level of arousal. He was born to a 24 year-old mother following an uncomplicated pregnancy by normal spontaneous vaginal delivery at 41 weeks gestational age. Apgar scores were 9 at 1 min and 9 at 5 min. He was discharged on the second postnatal day after circumcision.One day later he became sleepy, fed poorly and vomited approximately 10 times in 24 h. The baby was evaluated by a visiting nurse, who sent him to the emergency department. On examination he was moderately dehydrated, lethargic and poorly responsive to stimulation. Gastric lavage produced blood-tinged aspirates. Significant laboratory findings included glucose 27 mg/dl (normal: 45 to 120 mg/dl), Na 149 mEq/l (normal: 135 to 148 mEq/l), K 5.9 mEq/l, Cl 110 mEq/l (normal: 91 to 111 mEq/l), CO 2 18 mEq/l, BUN 40 mg/dl, creatinine 3.2 mg/dl (normal: 0.3 to 1 mg/dl), total serum bilirubin 9 mg/dl with a conjugated fraction of 1.4 mg/dl, serum ammonia 114 mmol/l (normal: 56 to 92 mmol/l), AST 718 IU/l (normal: 20 to 65 IU/l), ALT 978 IU/l (normal: <54 IU/L), PT 51.9 s (normal; 10.1 to 15.9 s), PTT 45.7 s (normal: 31.3 to 54.3 s), INR 5.4 (normal: 0.96 to 1.04), D-dimer 5.9 mg/l, factor V assay 57% and fibrinogen 61 mg/dl (normal: 1.67 to 3.09 g/l). A complete blood count revealed a WBC count of 13 600/mm, 2 hematocrit 66.4% and platelets of 154 000/mm. 3 Cerebral spinal fluid analysis was normal. The baby received intravenous volume expansion, dextrose and ampicillin and cefotaxime. He was admitted to the neonatal intensive care unit with a presumptive diagnosis of sepsis with renal failure, liver failure and coagulopathy. An arterial blood gas analysis after fluid boluses ...

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