Acute liver failure: Case

This girl presents severe acetaminophen-induced acute liver failure at 48 hours after a large intentional overdose. The international normalised ratio of 6.1, the markedly elevated transaminases, the grade two encephalopathy, the renal dysfunction, and the arterial pH of 7.26 confirm advanced hepatic failure with multiorgan involvement. The acetaminophen level being below the treatment line reflects the 48-hour interval but does not alter the management, because N-acetylcysteine is given regardless of the level once hepatotoxicity is established. ^[1]

Clinical findings

The pattern is unequivocally that of severe acetaminophen-induced acute liver failure at the peak of the hepatotoxic phase, which typically occurs around 72 hours after ingestion. The international normalised ratio of 6.1 reflects profound loss of hepatic synthetic function, the transaminases in the thousands indicate massive hepatocyte necrosis, and the falling arterial pH of 7.26 signals accumulating lactate and failing clearance, a grave prognostic sign. The grade two encephalopathy confirms that the failing liver is no longer clearing ammonia, and the renal dysfunction signals emerging multiorgan failure. ^[1]

The differential at presentation included other causes of acute liver failure, but the history of a large intentional acetaminophen overdose 48 hours earlier makes the diagnosis clear. The psychosocial context is essential: an intentional overdose in an adolescent requires parallel psychiatric assessment alongside the medical management, because the underlying self-harm behaviour determines the long-term outcome as much as the hepatic recovery. ^[1]