Paracetamol
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Paracetamol Pulmonary mucormycosis, dissemination of the mucormycosis following acute liver failure secondary to paracetamol overdose and toxicity: case report
A 60-year-old woman developed pulmonary mucormycosis, dissemination of the mucormycosis following acute liver failure secondary to paracetamol overdose and toxicity. The woman was admitted due to myalgia, fever, fatigue and non-productive cough for the past five days. She reported that these symptoms started to occur after she came in contact with an influenza-positive individual. Her medical history was significant for hypothyroidism and bipolar disorder. Upon further interrogation, it was revealed that she took paracetamol [acetaminophen] approximately 8–10g daily [route not stated] during the preceding week, due to disabling flu symptoms. Her home medications included lithium, quetiapine, levothyroxine, pregabalin and clonazepam. A subsequent abdominal ultrasound scan showed a normal liver volume, but a heterogeneous echogeneity was seen, without signs of chronic liver disease and along with hyperechogenicity of portal triads suggestive of acute hepatitis. This examination also demonstrated moderate ascites, anasarca and acute kidney injury with anuria. Serum paracetamol level was found to be at toxic level (358 µmol/L; paracetamol intoxication). Serological screening tests for autoimmune diseases resulted negative; however, test for influenza-B virus resulted positive. The woman was thus treated with oseltamivir. Within hours of hospital admission, her mental status deteriorated rapidly. She was placed on intubation and shifted to another hospital due to severe encephalopathy and hepatic failure following involuntary paracetamol intoxication. She was treated with acetylcysteine [N-acetylcysteine] and unspecified antibacterials. A high-volume of renal replacement therapy was given for acute kidney injury and hyperammonaemia to overcome the risk of intracranial hypertension. Two days after the admission, abdominal CT scan confirmed the presence of moderate ascites, otherwise showed a normal result. Following three days of supportive care, the liver function tests and liver enzymes showed a significant improvement. On hospital day 4, her chest X-ray revealed a new infiltrate in the left lingula along with on-going leucocytosis and fever. Her chest CT scan on hospital day 6 showed a consolidation in the lingula along with ground glass opacities. At the same time, the first endotracheal aspirations sampled showed a positive result for galactomannan antigen testing and grew filamentous fungi. Empirical therapy with voriconazole for coverage of presumed aspergillosis was added to the on-going antibacterial therapy. On hospital day 7, identified fungal growth was reported to be presumptive Mucorales species. A diagnosis of pulmonary mucormycosis was thus made. The anti-fungal therapy was changed to amphotericin-B liposomal [liposomal amphotericin-B]. On hospital day 8, bronchoscopy showed ulcerated tissue with necrosis in the lingula region. On hospital 1
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