A 24-year-old woman was admitted to the emergency department after ingesting ∼8000 mg (153.8 mg/kg) of acetaminophen in 12 h. She arrived at the emergency room after closely spaced ingestion of 4 tablets every 3 h for a total of 16 tablets from 08:00 to 22:00. On admission, the patient was mentally alert, although she suffered from epigastric pain, nausea, and vomiting. Vital signs upon arrival at our emergency department were as follows: blood pressure, 110/80 mm Hg; pulse rate, 66 times/min; respiratory rate, 20 times/min; and body temperature, 37.0°C. The patient reported direct tenderness around the epigastric area. However, she did not show signs of rebound tenderness or costovertebral angle tenderness.\nN-acetylcysteine was administrated for 20 h, ∼13 h after the first intake of acetaminophen by the patient. C-reactive protein (CRP), glutamic oxaloacetic transaminase (GOT), glutamic pyruvic transaminase (GPT), and white blood cell (WBC) counts were normal. However, PCT was measured at 31.89 ng/mL at ∼60 h after the first intake of acetaminophen by the patient. Acetaminophen drug level was <5.0 μg/mL at ∼27 h after the first intake of acetaminophen. All laboratory results are summarized in Table . An ultrasound did not reveal any abnormal hepatic parenchymal echogenicity or bile duct dilatation. There were no indications suggesting the probability of infection such as rigor or fever. The patient was discharged from the hospital without complications four days after she was first admitted to the emergency department.
A 70-year-old woman with a 9-year history of PD was admitted to the emergency department (ED) with a 1-day history of altered consciousness, fever, and convulsive movements. She was already bedridden (Hoehn and Yahr scale 5) and had left hand tremor. Her medications included carbidopa/levodopa (25 mg/100 mg per oral [PO] three times a day) and memantine (10 mg PO twice a day). Her family member informed us that she had taken her antiparkinsonian medications regularly before admission to the ED and that she had recurrent diarrhea with poor oral intake 1 week before the ED visit. After the recurrent diarrhea 1 week before the ED visit, the left hand tremor was aggravated. At admission, her vital signs included a blood pressure of 100/60 mmHg, temperature of 39.0°C, respiratory rate of 24 breaths/min, and heart rate of 138 beats/min. A physical examination showed hot and wet skin, rigidity of extremities, and left hand tremor. The patient showed seizure-like movements accompanied by leftsided eye deviation and muscle contraction 30 minutes after admission to the ED. The results of an arterial blood gas analysis showed respiratory alkalosis (pH 7.51, PaCO2 22 mmHg, PaO2 148 mmHg, and HCO3- 18.3 mEq/L) via O2 face mask 10 L. The initial laboratory results showed a white blood cell count of 16.2 × 103/L, sodium at 146 mEq/L, blood urea nitrogen (BUN) at 34.4 mg/dl, creatinine at 0.6 mg/dl, creatinine kinase(CK) at 41 U/L, and C-reactive protein (CRP) < 0.5 mg/dl. The computed tomography (CT) scan of the chest and abdomen did not show any abnormal findings. The brain CT showed severe brain atrophy with communicating hydrocephalus, but the cerebrospinal fluid examination result was normal. An electroencephalogram showed no epileptiform abnormalities. There were no cultured bacteria in the patient’s blood or urine. Six hours after admission, the patient showed high fever (> 40°C). The blood pressure of this patient was 90/50 mm/Hg despite administering 1.5 L of 0.9% NaCl over 4 hours. At 12 hours after admission, blood pressure was decreased (systolic blood pressure of 40 mmHg) and her respiration was shallow. Then, we decided intubation and mechanical ventilation support, and the patient was given a vasopressor (norepinephrine 0.6 μg/kg/h IV). Central venous catheterization was performed via the right subclavian vein and central venous pressure was 3 mmHg. To control the fever, dantrolene sodium (40 mg IV) and a cooling blanket were used; as a result, her temperature decreased to 36°C 15 hours after admission. At 14 hours after admission, the laboratory results indicated sodium at 149 mEq/L, BUN at 63.3 mg/dl, creatinine at 1.6 mg/dl, serum procalcitonin (PCT) at 25.63 ng/ml, and myoglobin at 970.8 ng/ml but showed no elevated CRP (). Based on a presumptive diagnosis of severe pseudomembranous colitis due to a history of antibiotic use (ceftriaxone 2 g for 5 days) 1 month before and elevated PCT, oral vancomycin was given once. Urine output was decreased (< 0.4 ml/kg/h), and hence, continuous venovenous hemodiafiltration (CVVHDF) with Multifiltrate® (Fresenius Medical Care, Bad Homburg, Germany) for acute kidney injury and oligouria was applied at 20 hours after admission. At 43 hours after admission, the laboratory results showed elevated CK (274 U/L) and decreased PCT levels (9.79 ng/ml). Clostridium difficile and its toxins were not detected in the stool and results of polymerase chain reaction assays were negative. There was improvement in the renal function tests and oligouria, so CVVHDF was stopped at 56 hours after admission. Based on a diagnosis of MS in PD on the 4th hospital day (HD), the patient received antiparkinsonian drugs that had been taken previously via a Levin tube. The frequency of the left hand tremor decreased, and her consciousness recovered to its previous condition. Weaning and extubation were performed on the 12th HD. After conservative treatment, she was discharged on the 22nd HD after recovery to her previous condition before admission.