Valacyclovir-associated neurotoxicity treated with intensification of peritoneal dialysis

Abstract

We report a 57-year-old woman with end-stage renal disease (ESRD) on maintenance peritoneal dialysis (PD), who presented to the emergency room (ER) by ambulance with complaints of confusion and altered sensorium for 48 hours. She had been reviewed in a walk-in clinic 72 hours earlier and had been prescribed the standard 1000 mg three times per day of valacyclovir for an acute attack of shingles instead of 500 mg once a day on ESRD. In the ER, she received further 500 mg of intravenous acyclovir as herpes encephalitis was clinically suspected. CT of the brain and lumbar puncture were non-contributory to the diagnosis. Valacyclovir and acyclovir were discontinued when the diagnosis of valacyclovir-associated neurotoxicity became clinically evident. As the patient's Glasgow Coma Scale declined, we intensified her PD regimen from one to six exchanges per day and 24 hours later there was a significant neurological improvement.

Severe mental disorders following anti-retroviral treatment in a patient on peritoneal dialysis: A case report and literature review

“…Valacyclovir-associated neurotoxicity usually occurs within 48-72 h of treatment start, and the symptoms can be gradually relieved after the drug is discontinued for 4-14 d (Table 1). For the patient in the present study, the time of onset and duration of symptoms were similar to those reported in literature[14,16-25] (Table 1).…”

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

“…Peritoneal dialysis has also been used to treat acyclovir toxicity and some authors advocate intensification of this modality for better drug removal [23,24]. Shah et al, in a study of a single patient on continuous ambulatory peritoneal dialysis, found a total body clearance of 48.3 mL/min/1.73 m 2 BSA) and a CAPD clearance of 4.3 mL/min.…”

A Unique Case of Valacyclovir Toxicity and Pseudobulbar Affect in a Patient On Peritoneal Dialysis

“…Less common symptoms are dysarthria, myoclonus, and rhabdomyolysis [5]. These symptoms that have been reported occur in patients on either hemodialysis or PD and typically resolve two to seven days after removing the offending medication [5,6].…”

“…Cases of valacyclovir toxicity have typically reported that the toxicity occurs within 24 to 72 hours, and typical neurological symptoms include hallucinations, confusion, lethargy, fear of death, ataxia, and death [4]. Less common symptoms are dysarthria, myoclonus, and rhabdomyolysis [5]. These symptoms that have been reported occur in patients on either hemodialysis or PD and typically resolve two to seven days after removing the offending medication [5,6].…”