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. 2021 May 18;11:10515. doi: 10.1038/s41598-021-89716-0

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© The Author(s) 2021

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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Dysregulated Metabolism of Acetaminophen. (A). Ward hierarchical cluster heatmap of dysregulated drug metabolism in nonsurvivors. Concentration of metabolites is depicted by least squares means with red being increased concentration and blue as reduced concentration in the serum. Heatmap made utilizing JMP Genomics 8.0, https://www.jmp.com/en_us/software/genomics-data-analysis-software.html. (B) Accumulation of 2-methoxyacetaminophen derivatives are evidence of an overwhelmed NQO1/NQO2 redox process and accumulation of the quinone intermediate. As glutathione levels decline, methyl-derivatives accumulate, likely derived from the nucleophilic addition of water on the quinone intermediate followed by methylation. N-acetyl cysteine and acetyl cysteine conjugated to the quinone intermediate and the resulting adducts, cysteine-derivatives of acetaminophen accumulate in nonsurvivors. Metabolites selected are representative of the significantly different drug xenobiotics identified by the semiquantitative analysis.