الفهرس 
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Abstract
Paracetamol is the commonest over the counter drug used worldwide as an analgesic and antipyretic with a wide safety profile at the recommended therapeutic dosage. On the other hand, paracetamol overdose is reported as one of the commonest causes of drug-induced liver injury in the United States and as a common method of suicide especially among adults.
This study was done to evaluate the early predictive value of some hematological parameters as neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR) and red cell distribution width (RDW) in the prediction of acute liver injury among patients with acute paracetamol poisoning.
A total of 40 acutely intoxicated patients with acute single paracetamol overdose were selected from the Poison Control Center of Minia University Hospital who were admitted to the hospital during the period of 1st February 2022 to 31th January 2023. The chosen patients were males and females above 18 years of age.
As indicated in Rumack Mathew nomogram, patients were divided into 3 groups mild group which included 18 patients with calculated paracetamol plasma level 4 hrs post ingestion less than 150 μg /ml, moderate group included 14 patients with calculated paracetamol plasma level 4 hrs post ingestion ranging from 150-200 μg /ml and severe group included 8 patients with calculated paracetamol plasma level 4 hrs post ingestion more than 200 μg /ml.
All patients underwent the following. Sociodemographic study which included data concerning age, sex, body weight and residence (urban or rural). Furthermore, the mode of poisoning and delay time from overdose intake to hospital presentation were also recorded.
Clinical evaluation and detailed history taking in the form of intoxication data about drug dosage, route of administration, mode of poisoning, delay time, co-ingestions, history of addiction or any drug abuse and data about the overdose either single or multiple supra-therapeutic doses. Finally detailed past history if any hepatic or renal disease or history of alcoholism. Clinical examination of the patients was performed regarding vital data and gastrointestinal (GIT) or central nervous system (CNS) manifestations for every patient on admission in order to estimate the phase of toxicity and the need for NAC administration and ICU admission.
Regarding laboratory investigations, a sample of venous blood was extracted from each patient at the time of admission just after diagnosis of an acetaminophen overdose at least 4 hours from ingestion and before starting NAC therapy. Serum has been separated and used to estimate the following laboratory tests: Serum paracetamol plasma level, Liver enzymes (ALT and AST), Prothrombin time (PT) and international normalized ratio (INR), Renal function tests (urea and creatinine), Serum electrolytes (Na+ & K+ levels), Complete blood picture with white blood cell differential count. Apart from paracetamol plasma level all these laboratory tests were repeated for all examined patients as a follow up during hospital admission. Duration of hospital stay was recorded for each group.
Concerning sociodemographic study, the results of this study revealed that the age of patients ranged from 19 to 45 years in both sexes. Twenty-seven patients (67.5%) were females while 13 patients (32.5%) were males with a female to male ratio of 2.1:1. Measurement of patient’s body weight revealed weight ranging from 50 kg to 82 kg with the mean weight 66.4 ± 7.8 kg. 67.5% of patients came from urban areas and 32.5% from rural areas. The only mode of poisoning in our study was suicidal and the drug was in a tablet form and taken orally by all patients. The average time between overdose administration and admission in the Poison Control Center was 7.1±2.2 hours (range 3-15 hrs).
The mean ingested dose was (6.4, 8.6, 11.5) gm in mild, moderate and severe groups respectively with a statistically significant difference between them. The most common features of admission included: nausea, vomiting, abdominal and epigastric pain.
Significant increase in the calculated plasma paracetamol concentration at 4 hours post-ingestion (PRC)4h in severe and moderate groups in comparison with patients of mild group was recorded.
There was significant increase in ALT and AST values recorded after 24hrs of overdose intake during 2nd and 3rd days of hospital stay among patients of moderate and severe groups. Statistically significant differences between groups were recorded as regarding coagulation parameters PT and INR among patients of moderate and severe groups from 2nd day of admission and during the follow up.
There were insignificant changes in the levels of serum urea and creatinine and in the serum electrolyte Na+ and K+ level among patients in the 3 examined groups.
The calculated hematological ratios NLR, PLR and MLR showed significant increase that recorded from the day of admission and during the follow up among patients of moderate and severe groups in comparison with patients of mild group. On the other hand RDW parameter showed insignificant changes among patients of the 3 examined groups either on admission or during the follow up.
Spearman’s correlation between case severity and different hematological parameters of the current study revealed significant positive correlation (P-value <0.001) between NLR, PLR and MLR parameters and the case severity from day of admission and during follow up. However RDW revealed insignificant correlation with case severity at the day of admission (P value 0.269) and during follow up.
Area under the ROC curve was 0.951 (95% CI = 0.832-0.994, P< 0.001) for neutrophil to lymphocyte ratio (NLR) on admission indicating excellent predictive performance, at a cut-off value above 2.7 with sensitivity 81.82%, specificity 100% and accuracy 90%. For platelet to lymphocyte ratio (PLR) on admission the area under the ROC curve was 0.759 (95% CI = 0.598-0.880, P< 0.001) indicating fair predictive performance, at a cut-off value above 100 with sensitivity 95.45%, specificity 50% and accuracy 75%. For monocyte to lymphocyte ratio (MLR) on admission the area under the ROC curve was 0.893 (95% CI = 0.754-0.968, P< 0.001) indicating good predictive performance, at a cut-off value above 0.2 with sensitivity 86.36%, specificity 72.22% and accuracy 80%.
Concerning hospital stay in the present study, the mean duration of stay in hospital was 4.1± 1.4 days. There was a significant difference between the 3 examined groups regarding duration of hospital stay as longer duration was recorded in moderate and severe groups when compared with mild group.
All examined patients intoxicated with paracetamol received the general treatment which included emesis or gastric lavage and activated charcoal administration. Patients of moderate and severe groups received antidotal therapy through intravenous administration of N-acetylcysteine over a period of 21hrs.
No mortality was recorded in this study and all patients were discharged after successful treatment protocol.