(887) Fulminant Hepatic Failure in the Setting of Toxic Acetaminophen and Iron Coingestion

Introduction: Fulminant hepatic failure in the setting of toxic ingestion of either acetaminophen or iron is well documented, with hepatoxicity occurring via multiple pathophysiologic mechanisms. The co-ingestion of acetaminophen and iron is observed to lead to rapid hepatic failure, as documented in adult literature. Below we describe a pediatric case demonstrating this, highlighting the need for screening for iron overdose.

Description: A 14-year-old female presented to the pediatric intensive care unit with a working diagnosis of intentional acetaminophen ingestion. N-acetylcysteine infusion was started at an outside facility and fomepizole was given on arrival. Serial lab values demonstrated acute hepatic failure out of proportion to acetaminophen level (12-hour post-ingestion: 85 ug/mL). Additional history obtained 24 hours into admission revealed potential iron co-ingestion. Lab values confirmed iron ingestion, with multiple radiopaque tablets identified on abdominal x-ray. Chelation was initiated with deferoxamine and whole bowel irrigation commenced. She developed significant hyperammonemia with encephalopathy and coagulopathy requiring continuous renal replacement therapy, extracorporeal liver support, and plasmapheresis. On hospital day three, the patient developed vasoplegia refractory to multiple vasoactive infusions. The patient was evaluated for emergent liver transplant but was not a candidate due to ongoing hemodynamic instability. With deteriorating hemodynamics and a poor neurologic exam, the patient’s family elected for withdrawal of life-sustaining therapies.

Discussion: Toxic ingestion of acetaminophen or iron can independently lead to fulminant hepatic failure, and co-ingestion could hasten this outcome. Lab tests such as serum acetaminophen, ethanol, methanol, and salicylate levels are often empirically obtained on patients presenting with intentional ingestion. Prompt initiation of chelation therapy is essential for successful treatment of severe iron toxicity due to rapid intracellular sequestration of iron. Given the ubiquity of iron-containing supplements and widespread availability of chelation therapy, one should consider the addition of iron levels to the empiric intentional ingestion workup.