Treatment of Massive Paracetamol Overdose with Hemodialysis and Fomepizole; A Case Report

Paracetamol is often involved in (intentional) overdose, resulting in roughly 2,600 annual hospitalizations in the United States and being the second most common cause of liver transplantation worldwide.In massive overdose (ingestion of > 500 mg/kg), standard treatment protocol alone may be insufficient.A few articles have described additional treatments, such as hemodialysis and fomepizole, to be useful.We present the case of a 23-year-old Caucasian woman who was unconscious at the emergency department after ingesting 75 g of paracetamol via a nasogastric tube.Her serum paracetamol level was 933 mg/L, with metabolic acidosis and an elevated lactate of 9.7 mmol/L.The patient was treated with the standard combination of activated charcoal, sodium sulfate, and N-acetylcysteine.Because of the severity of the intoxication, hemodialysis and off-label fomepizole were added to the standard treatment plan.Serum paracetamol level showed an accelerated decrease during hemodialysis and fomepizole.The patient recovered without signs of hepatotoxicity and seven days after the paracetamol ingestion, she was discharged from hospital.We suggests that there is a role for hemodialysis and fomepizole in the successful treatment of a massive paracetamol overdose.