A cautionary tale of pediatric paracetamol poisoning in a low-resource setting in Kenya: a case report and review of the literature

Paracetamol has a wide safety margin at therapeutic doses but overdose may cause life-threatening hepatotoxicity particularly in children. We report a case of a 3-year-old African female who presented to Malindi Sub County Hospital (MSCH) with severe dehydration, pneumonia, and convulsions. A detailed clinical history from her grandmother and medication reconciliation at the hospital revealed that she had inadvertently received a 5000 mg supratherapeutic dose of paracetamol over 48 h. Liver function tests (LFTs) showed marked amino transferases (peak ALT: 1566.2 IU/L, AST: 302.3 IU/L), rising gamma-glutamyl transferase (GGT) and hypoalbuminemia. Clinical coagulopathy was suspected based on blood oozing at the cannula site and epistaxis triggered by nasogastric tube insertion. Given the resource-limited nature of MSCH, measurements on serum paracetamol, international normalized ratio (INR), and prothrombin time (PT) were not done prompting empirical administration of fresh frozen plasma (FFP). N-acetylcysteine (NAC) was initiated more than 84 h after paracetamol exposure due to regional stockouts and barriers in procurement. Despite this delay, patient liver enzymes improved rapidly (ALT: 431.1 IU/L, AST: 105.6 IU/L) and she regained consciousness several hours post-NAC administration. This case report highlights how system failures in a resource-limited setting may compromise the management of paracetamol poisoning. This case highlights how system failures such as medication errors, misdiagnosis, poor caregiver education, and limited antidote access in resource-limited healthcare settings may result in sub-optimal care in pediatric paracetamol poisoning. Proper history taking, patient examination, and medication reconciliation are key in managing suspected paracetamol poisoning. Fortunately, even the late administration of N-acetylcysteine (> 24 h) abrogates severe hepatotoxicity in children with paracetamol poisoning. The close monitoring of liver function and clinical status is essential in managing pediatric paracetamol poisoning.