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Nishimura Y, Kewcharoen J, Narimasu T. Extremely Elevated Procalcitonin in a Case of Acetaminophen Overdose and Acute Liver Injury. Intern Med 2022; 61:115-118. [PMID: 34176834 PMCID: PMC8810263 DOI: 10.2169/internalmedicine.7192-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 05/10/2021] [Indexed: 11/27/2022] Open
Abstract
We herein report a 46-year-old man who suffered an intentional acetaminophen overdose. Laboratory results revealed leukocytosis and an elevated procalcitonin level (8.48 ng/mL). Computed tomography showed findings suggesting possible colitis. Due to concerns about sepsis in addition to acetaminophen overdose, oral N-acetyl cysteine and piperacillin/tazobactam were started. His procalcitonin levels further increased; however, the patient remained afebrile, and the C-reactive protein levels were normal. Piperacillin/tazobactam was discontinued, and he remained stable without antibiotics. The present case shows that the toxicokinetics of acetaminophen overdose can cause an elevated procalcitonin level. Furthermore, procalcitonin levels alone should not guide the need for antibiotics in such cases.
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Affiliation(s)
- Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai 'i, USA
| | - Jakrin Kewcharoen
- Department of Medicine, John A. Burns School of Medicine, University of Hawai 'i, USA
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Li YR, Meng XY, Zong RQ, Wu FX. Association Between Procalcitonin and Post-hepatectomy Liver Failure in Hepatocellular Carcinoma Patients. Front Pharmacol 2021; 12:791322. [PMID: 34867427 PMCID: PMC8637728 DOI: 10.3389/fphar.2021.791322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/03/2021] [Indexed: 12/01/2022] Open
Abstract
Objectives: Procalcitonin (PCT) has long been proved as an early diagnostic signal for postoperative outcomes. The purpose of this study is to explore the value of serum procalcitonin levels in predicting post-hepatectomy liver failure (PHLF), and further to declarethe relationship between postoperative PCT and short-term prognosis in patients after hepatectomy. Methods: Clinical data of patients with hepatocellular carcinoma (HCC) who underwent hepatectomy from June 1st, 2019 to September 31st, 2020 at Shanghai Eastern Hepatobiliary Surgery Hospital had been retrospectively analyzed. Logistic regression analysis was used to evaluate the risk factors related to PHLF. The Kaplan-Meier method was used to calculate the PHLF rate and 30-day survival after surgery. Results: A total of 885 patients with complete data were finally included in analysis, 311 of them with elevated serum PCT (≥1 ng/ml). Results of the logistic regression analysis suggested a significant association between PCT and PHLF [HR, 95%CI; 3.801 (1.825, 7.917), p < 0.001]. Other significant risk factors for PHLF included portal hypertension, portal blocking time (>30 min) and blood transfusion (>200 ml). Kaplan-Meier analysis also suggested a higher PHLF rate in elevated PCT patients [9.0% (95% CI, 7.3 to 12.8 VS. 1.9% (95% CI, 1.1–4.3)); p < 0.001]. For secondary outcomes, elevated PCT was also highly associated with postoperative sepsis, ICU admission, 30-day mortality and 3-month mortality. Conclusion: Elevated procalcitonin level in patients after hepatectomy is related to higher PHLF rate, with lower 30-day survival and poor short-term postoperative outcomes.
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Affiliation(s)
- Yi-Ran Li
- Department of Intensive Care Medicine, Eastern Hepatobiliary Surgery Hospital, The Third Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Xiao-Yan Meng
- Department of Intensive Care Medicine, Eastern Hepatobiliary Surgery Hospital, The Third Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Rui-Qing Zong
- Department of Intensive Care Medicine, Eastern Hepatobiliary Surgery Hospital, The Third Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Fei-Xiang Wu
- Department of Intensive Care Medicine, Eastern Hepatobiliary Surgery Hospital, The Third Affiliated Hospital of Naval Medical University, Shanghai, China
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Nuzzo A, Salem S, Malissin I, Diallo A, Deye N, Goury A, Gourlain H, Péron N, Vicaut E, Voicu S, Mégarbane B. Plasma procalcitonin may be an early predictor of liver injury in acetaminophen poisoning: A prospective cohort study. United European Gastroenterol J 2021; 9:571-580. [PMID: 34181312 PMCID: PMC8259278 DOI: 10.1002/ueg2.12093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/26/2021] [Indexed: 01/16/2023] Open
Abstract
Background and Aims Acetaminophen is a common cause of poisoning and liver injury worldwide; however, patient stratification is suboptimal. We aimed to assess the contribution of admission plasma procalcitonin concentration (PCT) to better identify acetaminophen‐poisoned patients likely to develop liver injury. Methods We conducted a prospective observational cohort study including all acetaminophen‐poisoned patients requiring N‐acetylcysteine admitted in a toxicological intensive care unit between 2012 and 2017. Multivariate analysis was performed using a Cox regression model to investigate factors associated with liver injury, defined as an increase in alanine aminotransferase (ALT) >100 IU/L. Results One hundred seventeen patients (age, 32 years (21–53), median [25th–75th percentiles]) were included after self‐ingesting 16 g (9–30) acetaminophen and received N‐acetylcysteine infusion administered within a median 6 h‐delay (4–12) from exposure. Co‐ingestions were reported in 77% of patients. Rumack–Matthew nomogram was non‐interpretable in 47% cases. Liver injury occurred in 38 patients (32%) with a median peak ALT of 2020 IU/L (577–4248). In liver injury patients, admission PCT was significantly increased in comparison to patients without liver injury (21.5 ng/ml (3.2–44.9) versus 0.1 ng/ml (0–0.4), respectively, p < 0.01). The increase in PCT preceded the increase in ALT by 33 h (10–74). In a multivariate analysis, PCT > 1 ng/ml was significantly associated with liver injury (hazard ratio, 7.2 [95% confidence interval, 2.3–22.6; p < 0.001]). PCT (area under the receiver‐operating characteristics curve, 0.91 [95%CI: 0.84–0.97]) predicted liver injury with sensitivity, specificity, negative, and positive predictive values of 0.92, 0.84, 0.96, and 0.73, respectively. Conclusion PCT on admission is associated with liver injury in acetaminophen poisoning. PCT might be used as a predictive tool of liver injury to improve clinical decision‐making.
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Affiliation(s)
- Alexandre Nuzzo
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France.,Department of Gastroenterology, APHP, Beaujon Hospital, Paris University, INSERM UMRS-1148, Clichy, France
| | - Shireen Salem
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Isabelle Malissin
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Abdourahmane Diallo
- Department of Epidemiology, APHP, Biostatistics and Clinical Research, Fernand-Widal Hospital, Paris University, Paris, France
| | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Antoine Goury
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Hervé Gourlain
- APHP, Laboratory of Toxicology, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Nicolas Péron
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Eric Vicaut
- Department of Epidemiology, APHP, Biostatistics and Clinical Research, Fernand-Widal Hospital, Paris University, Paris, France
| | - Sebastian Voicu
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, APHP, Lariboisière Hospital, Paris University, INSERM UMRS-1144, Paris, France
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Vogelbacher LC, Thimme R. [Unusual cause of a PCT-elevation]. Dtsch Med Wochenschr 2021; 146:818-820. [PMID: 34130324 DOI: 10.1055/a-1442-5519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Procalcitonin (PCT) is an established marker for bacterial infection. Elevation of PCT can occur due to various reasons and is not specific, as we outline in the following case report. HISTORY We report on a 29 year old patient, who was presented by the psychiatric department because of obscure abdominal pain, nausea and vomiting since two days. Taking the patients history did not result in conclusive findings at first. FINDINGS AND DIAGNOSIS The clinical examination did not result in conclusive findings. The patient was afebrile. Blood work showed an elevation of transaminases and a massive elevation of PCT. In ultrasound no abnormalities were shown, serological investigations for viral hepatitis were negative. Blood cultures remained sterile, the search for an infectious focus remained unremarkable. THERAPY AND COURSE In the course of the in-patient stay the patient reported the ingestion of approximately 40 g of acetaminophen in suicidal intention two days before. Therapy with N-acetylcysteine (NAC) was initiated. The transaminases and PCT were regressive the next day. Antibiotic therapy was foregone. CONCLUSIONS This case illustrates that PCT-elevation is not specific for a bacterial infection and must be seen in correlation to patient's history and clinical findings.
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Affiliation(s)
| | - Robert Thimme
- Klinik für Innere Medizin II, Universitätsklinikum Freiburg
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García de Guadiana Romualdo L, Rodríguez Rojas C, Ramos Arenas V, Cárdenas Gámez R, López Abellán MD, González Morales M. Increased concentrations of procalcitonin in patients with paracetamol intoxication. ADVANCES IN LABORATORY MEDICINE 2021; 2:287-295. [PMID: 37363327 PMCID: PMC10197320 DOI: 10.1515/almed-2020-0108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 10/01/2020] [Indexed: 06/28/2023]
Abstract
Objectives Paracetamol intoxication is one of the causes of elevated procalcitonin concentrations unrelated to infection. We report a case series of two patients intoxicated with paracetamol whose laboratory data revealed a significant elevation of serum procalcitonin concentrations without clinical, radiological and/or biological evidence of infection. The underlying mechanism by which paracetamol triggers an increase in procalcitonin concentrations is still unclear. Case presentation We report two cases of paracetamol intoxication. Both patients were admitted to the Emergency Department (ED) and subsequently transferred to the Intensive Care Unit (ICU). The patients exhibited elevated procalcitonin levels during the first hours of admission without clinical and/or microbiological evidence of infection that could explain such increase. Notably, only Case 1 developed liver injury, with alterations in alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin and esterified bilirubin concentrations, which were not observed in Case 2. Conclusions The two patients showed elevated procalcitonin concentrations resulting from paracetamol intoxication, although only a patient exhibited signs of liver injury. These findings suggest that increased procalcitonin levels induced by a paracetamol overdose cannot be fully explained by hepatocyte injury alone, but other mechanisms involving other organs and tissues may also be associated. In any case, although this mechanism is not well understood, it is important to be aware of this limitation when using procalcitonin as a biomarker of infection in patients intoxicated with paracetamol.
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Affiliation(s)
| | | | | | - Rubén Cárdenas Gámez
- Laboratory Medicine Department, Santa Lucía University Hospital, Cartagena, Spain
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Ahn JH, Cho YS, Cho GC. Elevated procalcitonin levels in patients with acetaminophen intoxication: two case reports: A CARE-compliant article. Medicine (Baltimore) 2020; 99:e18882. [PMID: 32049787 PMCID: PMC7035086 DOI: 10.1097/md.0000000000018882] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
RATIONALE Procalcitonin (PCT) is used as a biomarker for identifying the occurrence of sepsis. Previous studies have reported high levels of PCT with acetaminophen intoxication without evidence of infection. Here, we report two patients with acetaminophen intoxication with high levels of PCT without showing any symptoms of bacterial infection. PATIENT CONCERNS This case study examined two unrelated patients with acetaminophen intoxication admitted to emergency at different times. The first patient was admitted to the emergency department after ingesting approximately 8000 mg (153.8 mg/kg) of acetaminophen. On admission, C-reactive protein (CRP), glutamic oxaloacetic transaminase (GOT), and glutamic pyruvic transaminase (GPT) were normal. PCT and acetaminophen levels were 31.89 ng/mL and below 0.5 μg/mL, respectively. The second patient was admitted to the emergency department 8 h after ingesting ∼23,600 mg (280.6 mg/kg) of acetaminophen. By the second day of admission, GOT and GPT increased to 2508 and 1473 IU/L, respectively. PCT was 45.66 ng/mL with acetaminophen level at 116.9 μg/mL. Both patients were clear of symptoms associated with bacterial infection. DIAGNOSIS Acetaminophen intoxication. INTERVENTIONS N-acetylcysteine was given intravenously to both patients for 20 h per protocol. OUTCOMES Both patients were discharged without complications. LESSONS Observations suggests that elevated levels of PCT in patients intoxicated with acetaminophen may be associated with involvement of other organs impacted by cytokine stimuli from sterile inflammation resulting from hepatic damage rather than PCT secretion directly caused by hepatic cell damage.
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Affiliation(s)
- Jung Hwan Ahn
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon
| | - Young Suk Cho
- Department of Emergency Medicine, Kangdong Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Republic of Korea
| | - Gyu Chong Cho
- Department of Emergency Medicine, Kangdong Sacred Heart Hospital, Hallym University School of Medicine, Seoul, Republic of Korea
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Nezu K, Yoshioka T, Katayama H, Fukushi T, Kyan A. Spontaneous iliopsoas muscle hematoma secondary to disseminated intravascular coagulation caused by nafamostat mesilate allergy: a case study. RENAL REPLACEMENT THERAPY 2019. [DOI: 10.1186/s41100-019-0207-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Nezu K, Katayama H, Kyan A. Two cases of anaphylaxis due to contrast media during administration of nivolumab and ipilimumab in metastatic renal cell carcinoma. Int Cancer Conf J 2019; 9:36-40. [PMID: 31950016 DOI: 10.1007/s13691-019-00388-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/22/2019] [Indexed: 12/26/2022] Open
Abstract
A combination therapy of nivolumab and ipilimumab is effective for advanced renal cell carcinoma, but there are concerns about immune-related adverse events. A 46-year-old man was hospitalized for metastatic renal cell carcinoma. On day 9, he received nivolumab and ipilimumab. On days 16 and 49, he presented with fever, skin rash, and hypotension after contrast-enhanced computed tomography. A 70-year-old man was hospitalized for metastatic renal cell carcinoma. On day 9, he received nivolumab and ipilimumab. On day 44, he presented with fever, skin rash, and hypotension after contrast-enhanced computed tomography. Both patients were diagnosed with anaphylaxis due to the contrast agent.
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Affiliation(s)
- Kunihisa Nezu
- Department of Urology, Shirakawa Kousei General Hospital, 2-1, Kamiyazirou, Toyochi, Shirakawa, 961 0005 Fukushima Japan
| | - Hiromichi Katayama
- Department of Urology, Shirakawa Kousei General Hospital, 2-1, Kamiyazirou, Toyochi, Shirakawa, 961 0005 Fukushima Japan
| | - Atsushi Kyan
- Department of Urology, Shirakawa Kousei General Hospital, 2-1, Kamiyazirou, Toyochi, Shirakawa, 961 0005 Fukushima Japan
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