A 20-year-old woman with insignificant medical history was referred to our emergency department from another hospital for vomiting, fever, and impaired consciousness with a tentative diagnosis of bacterial meningitis. She had taken an over-the-counter antihistamine for pollinosis. Her vital signs on arrival were as follows: blood pressure 175/84 mmHg, heart rate 134 b.p.m., respiratory rate 28 breaths/min with an oxygen saturation of 96% on room air, and body temperature 38.0°C. Her Glasgow Coma Scale was 11 (E4V1M6), and we could not detect any significant neurological signs such as weakness of her limbs. Her pupils were bilaterally dilated to 5 mm. No nuchal rigidity or other meningeal signs were observed. Laboratory tests revealed glutamic oxaloacetic transaminase 30 IU/L, glutamic pyruvic transaminase 14 IU/L, C-reactive protein 0.43 mg/dL, white cell count 17,180/μL, (band cells 6.4%, segmented cells 89.4%, lymphocytes 2.2%, and monocytes 1.8%), and PCT over 10 ng/mL. Urine test, chest X-ray, computed tomography of the head, and cerebrospinal fluid test showed normal findings. We initially suspected systemic bacterial infection because of her fever and impaired consciousness, which is why we tested PCT. Although the cerebrospinal fluid test was normal, we cannot completely rule out bacterial infection due to the PCT elevation; therefore, we started treatment with empiric antimicrobials. Gradually, her level of consciousness improved; she confessed that she had taken 100 tablets of an ephedrine extract (Lipodrene, Hi-Tech Pharmaceuticals. Inc., Norcross, GA, USA), which contains caffeine (10 g), theophylline (amount unknown), yohimbine (amount unknown), and ephedrine (2.5 g), intending to commit suicide. We speculated that her low Glasgow Coma Scale on arrival was due to selective mutism because she had suicidal ideation and mood disorders. Her general condition stabilized, and blood tests showed no aggravation. Blood and cerebrospinal fluid culture results were negative on day 4. The PCT level decreased to 0.32 ng/mL on day 5, and she was discharged from hospital on the same day.
A 51-year-old man was admitted to emergency department at 8 h after ingesting 23,600 mg of acetaminophen (279.6 mg/kg). This patient was also mentally alert on admission. He explained that he felt generally weak without any discomfort. Vital signs on arrival in the emergency department were as follows: blood pressure, 100/60 mm Hg; pulse rate, 84 times/min; respiratory rate, 20 times/min; and body temperature, 36.0°C. A physical examination of the patient did not reveal anything unusual or anything out of the ordinary. N-acetylcysteine was also administered for 20 h ∼8 h after the first intake of acetaminophen by the patient. CRP, GOT, GPT, and WBC count were also normal.\nBy the second day of admission, GOT and GPT increased to 2508 and 1473 IU/L, respectively. Approximately at 56 h after first intake of acetaminophen, PCT level was elevated to 45.66 ng/mL. Acetaminophen drug level was 116.9 μg/mL. On the third day of admission, GOT and GPT decreased to 1382 and 1370 IU/L, respectively. Laboratory findings are summarized in Table . An ultrasound revealed a mild degree of fatty liver with hepatomegaly without bile duct dilatation. This patient did not show any signs associated with infection such as rigor or fever during his entire stay at the hospital. On the sixth day of admission, GOT and GPT was 53 and 357 IU/L, respectively. The patient was discharged since he did not show any unusual symptoms in addition to the daily decrease of his liver enzyme levels. He revisited to the out-patient department of gastroenterology the next day for a follow-up examination. There were no unusual symptoms. His liver enzyme returned to normal levels (GOT at 32 IU/L and GPT at 31 IU/L). The results of the laboratory tests performed in the out-patient department of gastroenterology are also summarized in Table .\nInformed consent was obtained for the current case report. Approval (IRB no. 2019-03-010) from the Institutional Review Board of Kangdong Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Republic of Korea, was obtained.