Acute Liver Failure Secondary to Niacin Toxicity

A 17-year-old male was transferred to the pediatric intensive care unit for evaluation of acute liver failure. He was recently released from an alcohol treatment center with acute onset of chest pain. Cardiac workup was negative but he was found to have abnormal coagulation studies and elevated liver transaminases. Other evaluations included a normal toxicology screen and negative acetaminophen level. Autoimmune and infectious workups were normal providing no identifiable cause of his acute liver failure. He initially denied any ingestions or illicit drug use but on further query he admitted taking niacin in an attempt to obscure the results of an upcoming drug test. Niacin has been touted on the Internet as an aid to help pass urine drug tests though there is no evidence to support this practice. Niacin toxicity has been associated with serious multisystem organ failure and fulminant hepatic failure requiring liver transplantation. Pediatric providers should be aware of the risks associated with niacin toxicity and other experimental medical therapies that may be described on the Internet or other nonreputable sources. 1. Introduction The Internet as a source of medical information and advice impacts the care that pediatricians provide for their patients [1, 2]. There is information available to teenagers on different supplements that can be consumed to mask illicit drug testing. The consequences are not readily considered by adolescents because they see them as easy to obtain over-the-counter medications; however, some of these supplements can be toxic or even lethal [3]. We present the case of an adolescent male who presented to our pediatric intensive care unit (PICU) with acute liver failure (ALF) secondary to niacin toxicity that was ingested as an effort to mask an upcoming drug screen. 2. Case A-17-year old male was transferred from an outside medical facility to the PICU for evaluation of ALF. He was recently released from an alcohol treatment center and presented to the outside hospital with acute onset of chest pain. Cardiac workup was negative but he was found to have significant laboratory abnormalities including abnormal coagulation studies with an international normalized ratio of 4.8 (normal 0.8–1.2), prothrombin time of 32.3 seconds (normal 9.5–13.8), and activated partial thromboplastin time of 47 seconds (normal 28–38 seconds). Liver transaminases were elevated with an aspartate transaminase of 295？U/L (normal 8–48？U/L), alanine transaminase of 284？U/L (normal 7–55？U/L), and total bilirubin of 8.4？mg/dL (normal 0.1–1.0？mg/dL) with a