Normal dose paracetamol in muscular dystrophy patients - is it normal?

A 16-year-old male with Becker muscular dystrophy was admitted to hospital with a significant liver injury due to paracetamol. The dosage of paracetamol ingested was within current guidance yet there was sudden derangement of liver function. The patient was treated with five days of N-acetyl cysteine to which he responded, with his alanine aminotransferase improving from 5,599 to 652 and international normalised ratio from 5.0 to 0.9. He had risk factors for paracetamol toxicity as he was malnourished and had muscular dystrophy. The purpose of this case report is to highlight that despite prescribing approved dosages of paracetamol some patients may have toxicity due to altered body composition and pharmacokinetics.