Any disease that affects liver and renal function or chronic medication (enzyme inhibitors) is a risk factor. In this case of paracetamol, viral hepatitis is likely contributing factor as fever is one of the symptoms. Therapeutic dose of paracetamol could have reached toxic plasma levels as a result of low protein binding (due to reduced synthetic function of the liver) leading to accumulation of toxic metabolite causing hepatocellular injury and renal tubular necrosis. Hepatocellular injury can be collectively seen as hyperenzymenia, hyperbilirubinemia and hypoalbuminemia.

HI, Mwila!

Thank you for your answer. This case is not simple for us. The patient didn't have low protein level and he didn't receive any medication except insulin before this situation. It's important information that his family already had lost one child (hypothetical from hemolytic-uremic syndrome) and he has healthy brother.

Hi Maria

It's indeed an interesting case! However, i would like to find out about the following: 1.What other prescription and non prescription drugs did the child receive 30 days before paracetamol?

2.Is there any drug that the child is hypersensitive to from the medical records at your hospital?

3. What medication did the child receive at the clinic where he was transported to?

4. Has the child been receiving the same brand of insulin or different brands? just verify if the batch of insulin brand is not adulterated with toxic compounds.

Hi, Mwila

Unfortunately, the patient had died few dayes ago. I don't know details yet.

I'll write you later, when the results of autopsia will be available.

Paracetamol poisoning ( Very rare cases ) -https://www.rch.org.au/clinicalguide/guideline_index/Paracetamol_poisoning/