N-Acetylcysteine Overdose: A Case Report
International Journal of Medical Toxicology and Forensic Medicine,
Vol. 11 No. 1 (2021),
23 January 2021
Background: N-Acetylcysteine (NAC) is a cost-effective antioxidant and very useful treatment for several diseases.
Methods: Here we report a rare case of iatrogenic NAC overdose following the mistake in calculation of the loading dose.
Results: The patient was 14 years old girl referred to a local hospital due to history of intentional ingesting about 7grams acetaminophen. The physician prescribed her 6 grams NAC as a loading dose but 42grams NAC were infused by mistake. After infusion, the patient showed signs of anaphylactic shock and then transferred to Imam Reza toxicology-unite with weakness, lethargy, extreme fatigue, nausea, and dizziness. NAC overdosing, in a short period of time, led to coagulopathy, reduced platelet count, acute renal failure and metabolic acidosis. After 24 h, the patient died. The Medical forensic examination showed minor lung hemorrhage and presence of little amount of Aluminum phosphide in tissues they did not find no vital organ hemorrhage. It is unclear related to NAC overdose, phosphine intoxication or synergic effects.
Conclusion: Massive transfusion of NAC was associated with impairment of coagulation factors, intracranial hypertension, renal failure and metabolic acidosis. Thus, NAC administration should be with caution. The medical history of patients committed suicide are not always accurate and complete evaluation are recommended.
- Medical error
- Aluminum phosphide
- Adverse drug reaction
How to Cite
Lee WM. Acetaminophen (APAP) hepatotoxicity-Isn’t it time for APAP to go away? J Hepatol. 2017; 67(6):1324-31. [DOI:10.1016/j.jhep.2017.07.005] [PMID] [PMCID]
Beltrán-Olazábal A, Martínez-Galán P, Castejón-Moreno R, García-Moreno ME, García-Muro C, Esteban-Zubero E. Management of acetaminophen toxicity: A review. Iberoamerican J Med. 2019; 1(1):22-8. http://dx.doi.org/10.5281/zenodo.3470262
Sanguinetti CM. N-acetylcysteine in COPD: Why, how, and when? Multidiscip Respir Med. 2015; 11:8. [DOI:10.1186/s40248-016-0039-2] [PMID] [PMCID]
Tunek A. Possible mechanisms behind the anti-inflammatory effects of N-acetyl cysteine: Is metabolism essential? Eur Respir Rev. 1992; 2(7):35-8.
Yarema MC, Johnson DW, Berlin RJ, Sivilotti ML, Nettel-Aguirre A, Brant RF, et al. Comparison of the 20-hour intravenous and 72-hour oral acetylcysteine protocols for the treatment of acute acetaminophen poisoning. Ann Emerg Med. 2009; 54(4):606-14. [DOI:10.1016/j.annemergmed.2009.05.010] [PMID]
Keays R, Harrison PM, Wendon JA, Forbes A, Gove C, Alexander GJ, et al. Intravenous acetylcysteine in paracetamol induced fulminant hepatic failure: A prospective controlled trial. BMJ. 1991; 303(6809):1026-9. [DOI:10.1136/bmj.303.6809.1026] [PMID] [PMCID]
Wright RO, Perry HE, Woolf AD, Shannon MW. Hemolysis after acetaminophen overdose in a patient with glucose-6-phosphate dehydrogenase deficiency. J Toxicol Clin Toxicol. 1996; 34(6):731-4. [DOI:10.3109/15563659609013837] [PMID]
Kanter MZ. Comparison of oral and i.v. acetylcysteine in the treatment of acetaminophen poisoning. Am J Health Syst Pharm. 2006; 63(19):1821-7. [DOI:10.2146/ajhp060050] [PMID]
Brok J, Buckley N, Gluud C. Interventions for paracetamol (acetaminophen) overdose. Cochrane Database Syst Rev. 2006; (2):CD003328. [DOI:10.1002/14651858.CD003328.pub2] [PMID]
Mahmoudi GA, Astaraki P, Mohtashami AZ, Ahadi M. N-acetylcysteine overdose after acetaminophen poisoning. Int Med Case Rep J. 2015; 8:65-9. [DOI:10.2147/IMCRJ.S74563] [PMID] [PMCID]
Heard K, Schaeffer TH. Massive acetylcysteine overdose associated with cerebral edema and seizures. Clin Toxicol (Phila). 2011; 49(5):423-5. [DOI:10.3109/15563650.2011.583664] [PMID]
Razlansari AA, Jafrasteh A, Garmsiri M. N-Acetylcysteine overdose after acetaminophen poisoning. Int J Adv Biol Biomed Res. 2017; 5(2):69-72. [DOI:10.26655/ijabbr.2017.3.4]
Niemi TT, Munsterhjelm E, Poyhia R, Hynninen MS, Salmenpera MT. The effect of N-acetylcysteine on blood coagulation and platelet function in patients undergoing open repair of abdominal aortic aneurysm. Blood Coagul Fibrinolysis. 2006; 17(1):29-34. [DOI:10.1097/01.mbc.0000195922.26950.89] [PMID]
Wijeysundera DN, Karkouti K, Rao V, Granton JT, Chan CT, Raban R, et al. N-acetylcysteine is associated with increased blood loss and blood product utilization during cardiac surgery. Crit Care Med. 2009; 37(6):1929-34. [DOI:10.1097/CCM.0b013e31819ffed4] [PMID]
Pizon AF, Jang DH, Wang HE. The in vitro effect of N-acetylcysteine on prothrombin time in plasma samples from healthy subjects. Acad Emerg Med. 2011; 18(4):351-4. [DOI:10.1111/j.1553-2712.2011.01041.x] [PMID]
Jang DH, Weaver MD, Pizon AF. In vitro study of N-acetylcysteine on coagulation factors in plasma samples from healthy subjects. J Med Toxicol. 2013; 9(1):49-53. [DOI:10.1007/s13181-012-0242-2] [PMID] [PMCID]
Jepsen S, Hansen AB. The influence of N-acetylcysteine on the measurement of prothrombin time and activated partial thromboplastin time in healthy subjects. Scand J Clin Lab Invest. 1994; 54(7):543-7. [DOI:10.3109/00365519409088566] [PMID]
Kim KY, Rhim T, Choi I, Kim SS. N-acetylcysteine induces cell cycle arrest in hepatic stellate cells through its reducing activity. J Biol Chem. 2001; 276(44):40591-8. [DOI:10.1074/jbc.M100975200] [PMID]
Marley R, Patel RP, Orie N, Ceaser E, Darley-Usmar V, Moore K. Formation of nanomolar concentrations of S-nitroso-albumin in human plasma by nitric oxide. Free Radic Biol Med. 2001; 31(5):688-96. [DOI:10.1016/S0891-5849(01)00627-X]
Miller LF, Rumack BH. Clinical safety of high oral doses of acetylcysteine. Semin Oncol. 1983; 10(1 Suppl 1):76-85. https://d1wqtxts1xzle7.cloudfront.net/50770520/100_-_Miller_Rumack_1983_Safety_Hi_Dose_NAC_Semin_Oncology.pdf?
Taromsar MR, Teymourpour P, Jahanbakhsh R. [Survey the histopathological findings in autopsy of poisoned patients with rice tablet (Aluminium Phosphide) (Persian)]. J Guilan Univ Med Sci. 2011; 19(76):56-63. http://journal.gums.ac.ir/article-1-171-en.html
Chugh SN. Aluminium phosphide poisoning: present status and management. J Assoc Physicians India. 1992;40(6):401-5. [PMID]
Dua R, Gill KD. Effect of aluminium phosphide exposure on kinetic properties of cytochrome oxidase and mitochondrial energy metabolism in rat brain. Biochim Biophys Acta. 2004; 1674(1):4-11. [DOI:10.1016/j.bbagen.2004.05.003] [PMID]
Arora B, Punia RS, Kalra R, Chugh SN, Arora DR. Histopathological changes in aluminium phosphide poisoning. J Indian Med Assoc. 1995;93(10):380-1. [PMID]
Sinha US, Kapoor AK, Singh AK, Gupta A, Mehrotra R. Histopathological changes in cases of aluminium phosphide poisoning. Indian J Pathol Microbiol. 2005;48(2):177-80. [PMID]
Singh S, Singh D, Wig N, Jit I, Sharma BK. Aluminum phosphide ingestion--a clinico-pathologic study. J Toxicol Clin Toxicol. 1996; 34(6):703-6. [DOI:10.3109/15563659609013832] [PMID]
- Abstract Viewed: 72 times
- pdf Downloaded: 22 times