Paracetamol has a wide safety margin at therapeutic doses but overdose may cause life-threatening hepatotoxicity particularly in children. We report a case of a 3-year-old African female who presented to Malindi Sub County Hospital (MSCH) with severe dehydration, pneumonia, and convulsions. A detailed clinical history from her grandmother and medication reconciliation at the hospital revealed that she had inadvertently received a 5000 mg supratherapeutic dose of paracetamol over 48 h. Liver function tests (LFTs) showed marked amino transferases (peak ALT: 1566.2 IU/L, AST: 302.3 IU/L), rising gamma-glutamyl transferase (GGT) and hypoalbuminemia. Clinical coagulopathy was suspected based on blood oozing at the cannula site and epistaxis triggered by nasogastric tube insertion. Given the resource-limited nature of MSCH, measurements on serum paracetamol, international normalized ratio (INR), and prothrombin time (PT) were not done prompting empirical administration of fresh frozen plasma (FFP). N-acetylcysteine (NAC) was initiated more than 84 h after paracetamol exposure due to regional stockouts and barriers in procurement. Despite this delay, patient liver enzymes improved rapidly (ALT: 431.1 IU/L, AST: 105.6 IU/L) and she regained consciousness several hours post-NAC administration. This case report highlights how system failures in a resource-limited setting may compromise the management of paracetamol poisoning. This case highlights how system failures such as medication errors, misdiagnosis, poor caregiver education, and limited antidote access in resource-limited healthcare settings may result in sub-optimal care in pediatric paracetamol poisoning. Proper history taking, patient examination, and medication reconciliation are key in managing suspected paracetamol poisoning. Fortunately, even the late administration of N-acetylcysteine (> 24 h) abrogates severe hepatotoxicity in children with paracetamol poisoning. The close monitoring of liver function and clinical status is essential in managing pediatric paracetamol poisoning.
Mongi et al. (Mon,) studied this question.