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 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.