A 22-year-old male referred to the Rheumatology Department with a history of Kaposiki disease at age 14.
Natural of Madrid.
No known adverse drug reactions or cardiovascular risk factors were reported.
There was no history of toxic consumption.
She had no family history of acute or chronic liver disease for up to two generations.
A person who had recently been diagnosed with acute Q fever lived unconfirmedly.
There was no history of autoimmune diseases in the family.
The patient visited the dentist 8 days before going to the emergency department for tooth extraction taking three capsules of 575 mg metamizole during that day as analgesic treatment.
She remained asymptomatic and 5 days later she presented with mild headache, myalgia, arthralgia and dysthermic sensation.
Therefore, he started treatment with ibuprofen, taking a total of 1,200 mg and 1 tablet paracetamol 500 mg with initial improvement.
A few hours later she had a fever of 38oC.
She was assessed by the Primary Care physician and was a member of the flu syndrome, so Algidal© (paracetamol 650 mg, codeine 10 mg and ascorbic acid) was prescribed.
Several hours later, a pruritic rash developed in the chest region.
For this reason, the combined medication was withdrawn and ibuprofen was again prescribed.
He came to the emergency room right now.
There was no history of consumption of herbal products, any type of dressing or feeding in possible bad condition.
There were no trips outside Spain in the recent past either.
The patient denied any sexual relationship outside his usual partner, tattoos, piercings or any other risky behavior.
On arrival to the emergency department, the patient was hemodynamically stable, with a bleaching abdomen that was presumable, tender for superficial spreading in emergency room with painful hepatomegaly, without ascitic semiology.
Skin examination revealed a pruritic macular exanthema of the troncular pruriginous and confluent upper limbs, which was mildly blind to the in vitropression, respecting palms and plants.
The rest of the examination was normal, including a deep neurological examination.
The analytical evolution can be seen in Table I. Chest X-ray showed no pathological changes.
Paul Bunnell's test was negative.
Abdominal ultrasound revealed abundant free peritoneal fluid and hepatomegaly without signs of thrombosis in portal and suprahepatic circulations.
An abundant number of activated lymphocytes were observed in the emergency peripheral blood smear.
Despite intense serum therapy and administration of vitamin K, the patient remained asymptomatic, with no analytical improvement of liver function, with maintenance of extreme coagulopathy and development of volume refractory hypotension.
It was decided to admit the patient to the Intensive Care Unit, from where she was referred to a hospital that had a hepatocyte transplantation unit and liver support system.
At hours, the patient developed clinical signs of hepatic encephalopathy, bilateral pleural effusion with respiratory failure, severe metabolic acidosis and worsening of the skin condition.
In the analytical evolution, the syndromic care is progressive, with a 48 hour figure of 4,270 eosinophils per microliter (18.7 mmol/L).
Because of their clinical condition, it was necessary to start external hepatic support with MARS (Molecular Adjustment System).
He was then included in the transplant protocol 0.
At 24 hours, the patient underwent liver transplantation from a cadaver donor (58 years, subarachnoid hemorrhage).
Postoperative recovery was uneventful and the patient was extubated 3 days later.
There was progressive improvement of cytolysis enzymes and persistence of coagulation with normalization of mild thrombopenia.
She was discharged several days later without further complications.
The serologies extracted on two occasions were negative for HAV, HBV, HCV, EBV, HSV, syphilis, HIV, CMV and parvovirus B19.
Blood paracetamol determination on admission was in a low range of toxicity and decreased to normal levels a few hours after treatment with N-acetylcysteine.
From the histopathological point of view, the explant findings are summarized in submassive confluent necrosis with polymorphic inflammatory reaction, hypereosinophilia and phlebitis suggestive of adverse hypersensitivity reaction.
