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It is 20 years since the NZMJ published a case report of paracetamol hepatotoxicity in a heavy drinker taking no more than 6 grams of paracetamol daily.1 Sporadic cases of life-threatening liver necrosis in heavy drinkers continue to be encountered in those taking alleged therapeutic doses of paracetamol, prompting us to report on a recent case.
Case report
A 52-year-old woman with a 12-year history of alcohol dependence was admitted electively for detoxification in December 2011. Her past medical history included possible seizure disorder (not treated with anticonvulsants), gastric bypass (admission weight 61 kg, body mass index 23 kg/m2), previous DVT, asthma and depression.
She was regularly drinking two bottles of wine per day up to the day of admission; breath alcohol on admission was 680 mcg/L. Examination showed mild tachycardia, tremor and right upper quadrant tenderness; there was no delirium, seizures or signs of liver failure.
Liver function tests (LFTs) 1 month earlier were consistent with alcoholic liver disease, with an ALT (alanine amino-transferase) of 146 U/L(<28), GGT (gamma-glutamyl transpeptidase) 212 U/L(<36), INR (international normalised ratio) 1.3, albumin 40 g/L (34-46), mean cell volume 103 fL, platelets 177×109/L; an AST (aspartate-aminotransferase) level was not taken.
On admission, her AST was markedly elevated at 1453 (<27 U/L), ALT 332, GGT 732, INR 2.5, albumin 27. Transaminases peaked the next day (AST 8015, ALT 1260). Serology for hepatitis B and C, Epstein-Barr virus and cytomegalovirus, and ANA were unremarkable. No contributing medications were noted; on admission she was taking omeprazole, citalopram (20mg daily), Symbicort® (budesonide with eformoterol) inhaler, zopiclone and multivitamins, and was treated for alcohol withdrawal with diazepam.
On enquiry, the patient reported using paracetamol for neck pain, as prescribed by her general practitioner (GP) at 4 grams a day for the preceding month. This was consistent with her pharmacy's dispensing records. Paracetamol was ceased on admission and she was administered the antidote NAC. Her LFTs improved markedly; by day 6 AST had fallen to 333, INR 1.4. She was discharged with strong advice to avoid paracetamol.
Unfortunately, she relapsed into alcohol abuse the next day. Two months later, a follow-up blood test by her GP revealed further hepatic insult with an AST of 3322, ALT 595 and INR 1.7. Remarkably, she admitted to resuming...