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.
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.