Acyclovir‐induced neuropsychosis successfully recovered after immediate hemodialysis in an end‐stage renal disease patient

Abstract

A 70-year-old man developed herpes zoster over the right L5-S2 region for 3 days and was admitted for acyclovir therapy. He had a medical history of rectal cancer status post-colostomy and end-stage renal disease undergoing thrice weekly hemodialysis. Without a prior loading dose, acyclovir 500 mg (7.7 mg/kg) daily was given intravenously in two divided doses. On the third dosage, the patient became confused and agitated and developed insomnia. Within the following 24 h, delirium, visual and auditory hallucinations, disorientation to place and time, as well as impaired recent memory occurred. At the same time, a transient low grade fever (38 degrees C) was noted but resolved spontaneously after ice pillow (Fig. 1). The etiology was vigorously explored. He had no history of any neurological or psychiatric disorders. Drug history was reviewed, but no other medications besides acyclovir were currently being used. Physical examination revealed neither meningeal signs nor focal neurological deficits. Serum blood urea nitrogen, glucose, and electrolytes were within normal limits except for an elevated creatinine level at 6.2 and 5.7 mg/dl (before and after neuropsychotic symptoms, respectively). Complete blood count with differentiation was also unremarkable. Cerebrospinal fluid examination was not possible as the patient's family refused the lumbar puncture. Moreover, an electroencephalograph study and head computed tomography scan disclosed no abnormalities. Acyclovir-induced neurotoxicity was suspected. Therefore, acyclovir was discontinued. Subsequently, serum acyclovir and CMMG were checked by enzyme-linked immunosorbent assay. Serum acyclovir level was 1.6 mg/l (normal therapeutic level, 0.12-10.8 mg/l) and CMMG level was 5 mg/l. Emergent hemodialysis (4-h/session) was given; the neuropsychotic symptoms, including agitation, delirium, and visual and auditory hallucinations, greatly abated after the second session. The patient fully recovered after three consecutive days of hemodialysis; the serum was rechecked and revealed that the acyclovir level was below 0.5 mg/l and the CMMG level was undetectable. At the same time, his herpetic skin lesions resolved well.

Brivudin induced delirium: a case report

“…Haemodialysis of the agent was also reported. 11 In conclusion, the present report describes a case of delirium following brivudin treatment. To our knowledge, no such side effect of brivudin has been observed to date.…”

“…Some drugs have been reported to cause delirium, including the antimicrobials, clarithromycin and ciprofloxacin, 7,8 and antivirals, such as oseltamivir and acyclovir. [10][11][12] However, there is no record concerning the present case of delirium due to brivudin treatment was encountered. The patient was not taking any other medications that included delirium as a side effect, and did not have any other conditions that would explain his symptoms.…”

“…The literature describing other drug-related delirium cases reinforces the likelihood of the causal relationship. [8][9][10][11][12] The situation requires verification with clinical studies and some patients might require dose adjustment to prevent possible delirious episodes. We found that treatment cessation was necessary for total recovery.…”

Herpetic Keratouveitis and Trabeculectomy Failure during Infliximab Therapy in a Patient with Behçet’s Disease

“…20 Acyclovir-induced neurotoxicity can present with a variety of symptoms including agitation, delirium and hallucinations. 21 Dose reductions are recommended in patients with renal impairment and in the elderly. Our patient received acyclovir at 800 mg/day for 24 months and a dose reduction was attempted, inflammation in the anterior chamber developed.…”

Herpes zoster encephalopathy or acyclovir neurotoxicity: a management dilemma

“…As opposed to zoster encephalitis, acyclovir neurotoxicity is associated with normal CSF findings and normal CT scan and MRI findings. Withdrawal of acyclovir often leads to resolution of neurological symptoms in 48–72 h,8 10 13 but some patients require haemodialysis 8 9 12 15. Some authors have suggested a therapeutic trial of haemodialysis to help distinguish the two conditions 8 9.…”