Death Delusions and Myoclonus: Acyclovir Toxicity

Gentry, James; Peterson, Cecily

doi:10.1016/j.amjmed.2015.03.001

Cited by 15 publications

(7 citation statements)

References 6 publications

(8 reference statements)

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“…Plasma levels are measured either by high-performance liquid chromatography or radioimmunoassay. High serum or CSF levels of the main acyclovir metabolite, 9- carboxymethoxymethylguanine (CMMG), are highly predictive of acyclovir neurotoxicity [19]. In a study of the serum levels of CMMG, receiver-operating characteristics curve analysis showed a sensitivity of 91% and specificity of 93% for the development of neuropsychiatric symptoms [20].…”

Section: Discussionmentioning

confidence: 99%

Acyclovir Neurotoxicity in a Peritoneal Dialysis Patient: Report of a Case and Review of the Pharmacokinetics of Acyclovir

2018

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Patient: Male, 80Final Diagnosis: Neurotoxicity due acyclovirSymptoms: Confusion • hallucinationMedication: AcyclovirClinical Procedure: —Specialty: NephrologyObjective:Unusual clinical courseBackground:The elderly population in the United States and the world is rapidly increasing. With aging, immunity and kidney function decrease, thus predisposing people to viral illnesses for which there is no effective prophylaxis. Herpes zoster afflicts the elderly and other immunocompromised patients, like those with end-stage renal disease, transplant recipients, and cancer patients, causing significant morbidity and sometimes mortality. Treating herpes zoster becomes problematic when the regular pharmacokinetics of the antiviral drugs are disturbed.Case Report:An 83-year-old African American man with end-stage kidney disease (ESRD) and on chronic peritoneal dialysis (PD) developed herpes zoster, for which he received the manufacturer-recommended intravenous dose of acyclovir. Shortly after taking the medication, he developed confusion, disorientation, and visual hallucinations. He was switched from PD to hemodialysis (HD), with successful recovery. Examination of the cerebrospinal fluid for meningitis and imaging studies of the head were negative. Serum levels of acyclovir were elevated.Conclusions:Even when the acyclovir dose is properly adjusted for kidney function based on the current manufacturer’s recommendations, it can cause neurotoxicity. Here, we discuss the pharmacokinetics of acyclovir and make some recommendations with regard to dose adjustment in patients with ESRD.

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Section: Discussionmentioning

confidence: 99%

Acyclovir Neurotoxicity in a Peritoneal Dialysis Patient: Report of a Case and Review of the Pharmacokinetics of Acyclovir

2018

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“…Ninety‐seven of those were included in the analysis, representing a total of 119 independent patients (Figure 1). The cases were extracted from 86 clinical cases 9‐35,37‐48,50‐54,56‐63,65‐71,73,75‐77,80‐83,85‐100,102,103 and 11 case series 36,49,55,64,72,74,78,79,84,101,113 . Figure 1 shows the case selection flow diagram.…”

Section: Resultsmentioning

confidence: 99%

Neurotoxicity associated with acyclovir and valacyclovir: A systematic review of cases

et al. 2021

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What is known and objective Acyclovir and valacyclovir are commonly used antivirals with good general tolerance. Despite their good safety profile, they can cause systemic adverse effects, such as neurotoxicity, which are less frequent and known. The objective of this review was to collect all the reported cases of neurotoxicity associated with acyclovir and valaciclovir published in the literature and characterize their clinical course and interventions. Methods A systematic review of cases was carried out following the guidelines established by “Preferred Reporting Items for Systematic Reviews and Meta‐Analyses” (PRISMA). The research was carried out using the PubMed‐Medline and Embase databases, between July 1984 and March 2021. Results and discussion A total of 119 cases with neurotoxicity mainly related to acyclovir (n = 88; 73.9%), followed by valaciclovir (n = 35; 29.4%) were analysed. 49.6% (n = 59) were men with a mean age of 59.5 years ± 21.1 (0.5–88). In 83.3% of the cases, renal impairment was documented and 57.1% (n = 68) with end‐stage renal disease. The administered dose was higher than the renal adjustment recommendations in 59.7% of the cases. The global mean of onset of symptoms was 3.1 days ± 4.3 (0.2–28) after the start of antivirals. The mean recovery time was 9.8 days ± 21.7 (0.2–180). 74.4% of the patients had a recovery of ≤7 days, 15.9% between 8 and 15 days and 9.8% > 15 days. What is new and conclusion The neurotoxicity induced by acyclovir and its derivative valacyclovir is a poorly known and rare adverse effect that can occur mainly in patients with advanced age and impaired renal function. The most characteristic symptoms are confusion, altered level of consciousness, hallucinations, agitation and dysarthria. The basis of treatment is the discontinuation of the antiviral, and in some cases, it may require additional clearance by dialysis.

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“… 6 , 7 Prior studies have shown that assessing for high concentrations of the effective metabolite of acyclovir, 9-carboxymethoxymethylguanine, in the serum and CSF is predictive of neurotoxicity. 10 – 12 Treatment of these patients requires thorough and frequent neurological exams to monitor for subtle changes in mental status. Involvement of neurology early can be beneficial as changes in mental status can be subtle and they can assist with alternate diagnoses.…”

Section: Discussion: Herpes Zoster Encephalopathy Versus Acyclovir Nementioning

confidence: 99%

Acyclovir-induced neurotoxicity in an immunocompromised patient

Marks

Paz

Walston

2020

SAGE Open Medical Case Reports

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This is a case report of a 75-year-old immunocompromised male who developed encephalopathy while undergoing treatment for disseminated herpes zoster with peripheral nerve involvement. While his initial presentation involved primarily profound lower extremity weakness, he developed progressive confusion to the point of obtundation only after initiation of standard therapy with intravenous acyclovir. The evaluation of his altered mental status was largely unremarkable. It was only after his acyclovir was discontinued that his symptoms resolved and he returned to his baseline mental status. His presentation was most consistent with acyclovir-induced neurotoxicity, which can present in patients with renal impairment and those who are immunocompromised.

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Death Delusions and Myoclonus: Acyclovir Toxicity

Cited by 15 publications

References 6 publications

Acyclovir Neurotoxicity in a Peritoneal Dialysis Patient: Report of a Case and Review of the Pharmacokinetics of Acyclovir

Acyclovir Neurotoxicity in a Peritoneal Dialysis Patient: Report of a Case and Review of the Pharmacokinetics of Acyclovir

Neurotoxicity associated with acyclovir and valacyclovir: A systematic review of cases

Acyclovir-induced neurotoxicity in an immunocompromised patient

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