J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website https://jmc.elmerpub.com

Case Report

Volume 17, Number 7, July 2026, pages 309-320

Supportive Management of Severe Acetaminophen and Ibuprofen Overdose Twenty-Four Hours After Ingestion in Limited Resources Settings

↓ **Table 1.** Transaminase Levels Over Time During Hospitalization
	Day
ALT: alanine aminotransferase; AST: aspartate aminotransferase.
ALT	726	11,224	10,540	6,349	4,637	2,881	2,319	1,442	1,288	1,039	686	498	383	247
AST	728	11,688	3,139	1,217	438	197	101	73	69	69	57	54	52	56
	18	20	22	24	27	34	37	41	47	49	50	51	52	53
ALT	174	115	95	88	70	66	84	72	95	90	82	91	104	88
AST	60	59	67	79	90	120	153	125	144	138	132	135	145	115

↓ Table 1. Transaminase Levels Over Time During Hospitalization

Day

ALT: alanine aminotransferase; AST: aspartate aminotransferase.

ALT

726

11,224

10,540

6,349

4,637

2,881

2,319

1,442

1,288

1,039

686

498

383

247

AST

728

11,688

3,139

1,217

438

197

101

ALT

174

115

104

AST

120

153

125

144

138

132

135

145

115

↓ **Table 2.** Blood Bilirubin Levels Over Time During Hospitalization
	Day
Total	3.04	4.04	4.60	5.58	7.19	9.22	14.22	15.59	22.98	26.31	25.22	24.63
Direct						4.81	8.84	9.27	13.33	16.40	16.44	20.15
	14	16	18	20	22	24	27	37	41	47	51	53
Total	26.93	30.76	33.47	32.61	35.65	35.58	33.40	32.92	32.05	23.7	17.4	16.1
Direct	20.09	20.74	22.82	23.15	24.01	24.43	25.23	23.20	22.99	18.46	13.90	13.20

↓ Table 2. Blood Bilirubin Levels Over Time During Hospitalization

Day

Total

3.04

4.04

4.60

5.58

7.19

9.22

14.22

15.59

22.98

26.31

25.22

24.63

Direct

4.81

8.84

9.27

13.33

16.40

16.44

20.15

Total

26.93

30.76

33.47

32.61

35.65

35.58

33.40

32.92

32.05

23.7

17.4

16.1

Direct

20.09

20.74

22.82

23.15

24.01

24.43

25.23

23.20

22.99

18.46

13.90

13.20

↓ **Table 3.** The INR Over Time During Hospitalization
	Day
INR: international normalized ratio.
INR	3.29	13.91	10.65	10.17	9.07	7.97	6.11	5.78	4.30	3.81	3.80	2.81	3.21	2.98
	18	20	22	24	27	30	34	37	41	47	50	51	52	53
INR	3.19	2.71	2.39	2.70	2.43	2.89	2.58	2.14	2.14	1.48	1.25	1.25	1.16	1.20

↓ Table 3. The INR Over Time During Hospitalization

Day

INR: international normalized ratio.

INR

3.29

13.91

10.65

10.17

9.07

7.97

6.11

5.78

4.30

3.81

3.80

2.81

3.21

2.98

INR

3.19

2.71

2.39

2.70

2.43

2.89

2.58

2.14

1.48

1.25

1.16

1.20

↓ **Table 4.** Blood Glucose Levels Over Time During Hospitalization
	Day
Glucose	101	36	33	51	32	63	47	98	89	90	86	74	100	94
	18	20	22	24	27	34	37	41	47	50	51	52	53
Glucose	83	102	78	117	121	76	87	69	83	89	159	95	106

↓ Table 4. Blood Glucose Levels Over Time During Hospitalization

Day

Glucose

101

100

Glucose

102

117

121

159

106

↓ **Table 5.** WBC Count Over Time During Hospitalization
	Day
WBC: white blood cell.
WBC	11.3	16.8	21.9	12.0	5.9	8.0	17.0	13.3	18.0	15.4	15.1	13.4	12.6	12.7
	18	20	22	24	27	30	34	37	41	50	51	52	53
WBC	9.0	7.9	8.8	9.1	12.7	6.2	10.3	15.1	14.9	10.15	9.08	10.47	10.31

↓ Table 5. WBC Count Over Time During Hospitalization

Day

WBC: white blood cell.

WBC

11.3

16.8

21.9

12.0

5.9

8.0

17.0

13.3

18.0

15.4

15.1

13.4

12.6

12.7

WBC

9.0

7.9

8.8

9.1

12.7

6.2

10.3

15.1

14.9

10.15

9.08

10.47

10.31

↓ **Table 6.** RBC Count Over Time During Hospitalization
	Day
RBC: red blood cell.
RBC	4.26	4.31	4.30	4.36	4.72	4.07	4.43	3.48	4.16	4.15	3.45	3.40	3.42	3.77
	18	20	22	24	27	30	34	37	41	50	51	52	53
RBC	3.61	3.25	3.25	3.20	3.23	3.19	3.13	3.26	2.95	2.95	3.14	3.47	3.33

↓ Table 6. RBC Count Over Time During Hospitalization

Day

RBC: red blood cell.

RBC

4.26

4.31

4.30

4.36

4.72

4.07

4.43

3.48

4.16

4.15

3.45

3.40

3.42

3.77

RBC

3.61

3.25

3.20

3.23

3.19

3.13

3.26

2.95

3.14

3.47

3.33

↓ **Table 7.** HgB Levels Over Time During Hospitalization
	Day
HgB: hemoglobin.
HgB	12.1	12.5	12.2	12.4	13.2	11.9	13.1	10.7	11.6	11.4	10.4	10.0	10.1	10.1
	18	20	22	24	27	30	34	37	41	50	51	52	53
HgB	9.8	9.1	9.4	9.4	9.6	9.6	9.8	9.6	9.7	9.4	9.9	11.2	10.9

↓ Table 7. HgB Levels Over Time During Hospitalization

Day

HgB: hemoglobin.

HgB

12.1

12.5

12.2

12.4

13.2

11.9

13.1

10.7

11.6

11.4

10.4

10.0

10.1

HgB

9.8

9.1

9.4

9.6

9.8

9.6

9.7

9.4

9.9

11.2

10.9

↓ **Table 8.** HCT Levels Over Time During Hospitalization
	Day
HCT: hematocrit.
HCT	36.8	37.6	35.1	37.1	37.6	34.3	37.8	30.2	33.7	33.7	30.2	29.6	29.3	28.6
	18	20	22	24	27	30	34	37	41	50	51	52	53
HCT	28.0	25.6	27.4	27.0	27.9	29.4	28.3	28.1	27.7	28.4	30.5	35.1	32.7

↓ Table 8. HCT Levels Over Time During Hospitalization

Day

HCT: hematocrit.

HCT

36.8

37.6

35.1

37.1

37.6

34.3

37.8

30.2

33.7

30.2

29.6

29.3

28.6

HCT

28.0

25.6

27.4

27.0

27.9

29.4

28.3

28.1

27.7

28.4

30.5

35.1

32.7

↓ **Table 9.** PLT Count Over Time During Hospitalization
	Day
PLT: platelet.
PLTs	181	152	149	147	163	164	160	127	126	128	107	102	106	91
	18	20	22	24	27	30	34	37	41	50	51	52	53
PLTs	80	87	118	159	215	161	172	194	144	150	155	180	177

↓ Table 9. PLT Count Over Time During Hospitalization

Day

PLT: platelet.

PLTs

181

152

149

147

163

164

160

127

126

128

107

102

106

PLTs

118

159

215

161

172

194

144

150

155

180

177

↓ **Table 10.** Acetaminophen Liver Damage Stages [5, 6]
Stage	Time frame	Clinical features	Laboratory/organ findings
CNS: central nervous system; PT: prothrombin time.
Stage I	30 min to 24 h	Possibly asymptomatic; nausea, vomiting, diaphoresis, pallor, lethargy, malaise	Transaminases usually normal (may rise after 8–12 h in large ingestions); possible CNS depression and high anion gap metabolic acidosis
Stage II	24–72 h	Apparent clinical improvement; right upper quadrant pain; hepatomegaly	Rising transaminases; worsening labs despite clinical improvement; increased PT and bilirubin; possible renal injury/oliguria; rare acute pancreatitis
Stage III	72–96 h	Severe symptoms: jaundice, encephalopathy, bleeding tendency; recurrence of early symptoms	Peak aminotransferases (> 10,000 IU/L); hyperammonemia; prolonged PT; hypoglycemia; lactic acidosis; indirect hyperbilirubinemia; acute renal failure common; highest mortality risk (multisystem organ failure)
Stage IV	≥ Day 4 (recovery phase)	Clinical recovery if survival of stage III	Gradual normalization of labs (weeks); histopathologic liver changes evident; typically, no long-term liver dysfunction or cirrhosis

↓ Table 10. Acetaminophen Liver Damage Stages [5, 6]

Stage

Time frame

Clinical features

Laboratory/organ findings

CNS: central nervous system; PT: prothrombin time.

Stage I

30 min to 24 h

Possibly asymptomatic; nausea, vomiting, diaphoresis, pallor, lethargy, malaise

Transaminases usually normal (may rise after 8–12 h in large ingestions); possible CNS depression and high anion gap metabolic acidosis

Stage II

24–72 h

Apparent clinical improvement; right upper quadrant pain; hepatomegaly

Rising transaminases; worsening labs despite clinical improvement; increased PT and bilirubin; possible renal injury/oliguria; rare acute pancreatitis

Stage III

72–96 h

Severe symptoms: jaundice, encephalopathy, bleeding tendency; recurrence of early symptoms

Peak aminotransferases (> 10,000 IU/L); hyperammonemia; prolonged PT; hypoglycemia; lactic acidosis; indirect hyperbilirubinemia; acute renal failure common; highest mortality risk (multisystem organ failure)

Stage IV

≥ Day 4 (recovery phase)

Clinical recovery if survival of stage III

Gradual normalization of labs (weeks); histopathologic liver changes evident; typically, no long-term liver dysfunction or cirrhosis

↓ **Table 11.** General Supportive Treatment’s Modalities [18]
System/complication	Supportive measures
FFP: fresh frozen plasma; ICP: intracranial pressure; ICU: intensive care unit.
General/ICU care	Continuous monitoring of vital signs, neurological status, labs; manage fluids and electrolytes; ICU admission required
Hemodynamic	Maintain blood pressure and organ perfusion; use fluids and vasopressors as needed; avoid fluid overload
Cerebral edema/intracranial hypertension	Elevate head of bed, normothermia, sedation; osmotic therapy (mannitol) if ICP rises; avoid hypercapnia and hyponatremia
Coagulation	Correct only if active bleeding or invasive procedures; routine prophylaxis not recommended; use FFP/platelets selectively
Renal	Monitor kidney function; initiate renal replacement therapy for severe metabolic derangements or volume overload
Infection	Frequent microbiological monitoring: prompt antibiotic/antifungal therapy if infection develops
Metabolic/nutrition	Maintain glucose homeostasis; enteral nutrition preferred; parenteral if enteral contraindicated
Respiratory	Mechanical ventilation if severe encephalopathy or respiratory failure develops

↓ Table 11. General Supportive Treatment’s Modalities [18]

System/complication

Supportive measures

FFP: fresh frozen plasma; ICP: intracranial pressure; ICU: intensive care unit.

General/ICU care

Continuous monitoring of vital signs, neurological status, labs; manage fluids and electrolytes; ICU admission required

Hemodynamic

Maintain blood pressure and organ perfusion; use fluids and vasopressors as needed; avoid fluid overload

Cerebral edema/intracranial hypertension

Elevate head of bed, normothermia, sedation; osmotic therapy (mannitol) if ICP rises; avoid hypercapnia and hyponatremia

Coagulation

Correct only if active bleeding or invasive procedures; routine prophylaxis not recommended; use FFP/platelets selectively

Renal

Monitor kidney function; initiate renal replacement therapy for severe metabolic derangements or volume overload

Infection

Frequent microbiological monitoring: prompt antibiotic/antifungal therapy if infection develops

Metabolic/nutrition

Maintain glucose homeostasis; enteral nutrition preferred; parenteral if enteral contraindicated

Respiratory

Mechanical ventilation if severe encephalopathy or respiratory failure develops