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Various toxicities: case report A 17-year-old girl developed hepatotoxicity and INR elevation secondary to acute paracetamol toxicity following intentional misuse of paracetamol for analgesia. Additionally, she developed delayed anaphylactoid reaction during treatment with acetylcysteine for paracetamol toxicity [not all dosages stated]. The girl presented with complaints of vomiting, nausea and abdominal pain 10 hours following acute paracetamol [acetaminophen] ingestion. On presentation, she was well-appearing. She reported ingesting four tablets of unknown strength for analgesia and completely denied any suicide attempt. Serum drug concentration at 11 hours post-ingestion was found to be elevated. The girl was treated with three bags of IV acetylcysteine [N-acetylcysteine]. She was transferred to the intensive care unit of another hospital, where the third bag of acetylcysteine was continued at 6.25 mg/kg/h. Ten hours later, her transaminases increased further with elevation of INR at 21 hours post-ingestion of paracetamol. At the end of 21 hour protocol (33 hours post-ingestion of paracetamol), her transaminases continued to increase and acetylcysteine was continued at the same dose. Approximately 3.5 hours after the initiation of the fourth bag of acetylcysteine (24.5 hours into her continuous infusion), she reported throat itching and a low-grade fever with headache, rhinorrhoea and diarrhoea. She further developed bilateral wheezing, angioedema and subcostal retractions with respiratory distress. She was lethargic, tachypneic and tachycardic. Acetylcysteine was discontinued. She received treatment with methylprednisolone sodium succinate [Solumedrol], diphenhydramine, epinephrine, salbutamol [albuterol] and racepinephrine [racemic epinephrine]. Her respiratory symptoms had improved; however, swelling of the lips and facial oedema persisted. The toxicology team recommended re-initiation of IV acetylcysteine at double the previous rate with concurrent prophylactic therapy for resolution of the respiratory distress due to high risk of fulminant hepatic failure (FHF) associated with late hospital presentation, elevated serum drug concentration and elevated transaminases. She was re-initiated on acetylcysteine after a 3-hour break at 12.5 mg/kg/h along with unspecified steroids and antihistamines. Due to uncertain prognosis, liver transplant service was consulted. Acetylcysteine was continued at rate of 12.5 mg/kg/h along with unspecified steroids and antihistamines. There was no recurrence of anaphylactoid symptoms as she was concurrently treated with unspecified steroids and antihistamines for prevention of the symptoms from recurring. She consistently denied suicidal ideation; however, a psychiatry evaluation was advised due to self-reported ingestion inconsistent with clinical course (misuse). She was normal and discharged six days later. Follow-up five months after discharge confirmed that she was clinically well. Epperson LC, et al. A Case Report of a Severe, Unusually Delayed Anaphylactoid Reaction to