title: Valacyclovir and Acyclovir Neurotoxicity With Status Epilepticus.
abstract: We present the case of a 52-year-old man with hypertension, diastolic congestive heart failure, end-stage renal disease on hemodialysis 3 times a week and a remote history of a hemorrhagic stroke who presented to the emergency department with a vesicular rash on his left arm. The rash was observed to be in a dermatomal distribution, and a diagnosis of herpes zoster was made. The patient was discharged home on valacyclovir 1 g 3 times a day for a duration of 7 days. The patient took 2 doses of valacyclovir before presenting to the hospital again with irritability and hallucinations. Over the next several days, the patient's neurologic status declined and he became disoriented and increasingly somnolent. Because of a concern for varicella zoster virus (VZV) or herpes simplex virus (HSV) meningoencephalitis, acyclovir was initiated intravenously at 600 mg (10 mg/kg) for every 12 hours. Computed tomography and magnetic resonance imaging of the brain failed to reveal an acute process. Electroencephalogram was interpreted as seizure activity versus metabolic encephalopathy. Lumbar puncture was not suggestive for meningitis, subarachnoid hemorrhage, or HSV/VZV infection. The patient subsequently had a witnessed seizure during dialysis and was felt to have status epilepticus due to acyclovir and valacyclovir neurotoxicity. The patient underwent daily hemodialysis for removal of the drug and eventually made a full neurologic recovery. Our case highlights that acyclovir neurotoxicity can result in status epilepticus, hallucinations, and altered consciousness. Differentiating acyclovir neurotoxicity from HSV or VZV meningoencephalitis is of crucial importance because the symptoms are similar but the management is vastly different.
authors.affiliation: 1Department of Medicine, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons; 2Section of Critical Care, Department of Medicine, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons; and 3Division of Nephrology, Department of Medicine, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY; 4Department of Neurology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY. †Present address: Dr. Hoskote is now with the Division of Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN; ‡Present address: Dr. Annapureddy is now with the Division of Rheumatology, Department of Medicine, Rush University Medical Center, Chicago, IL.
authors.forename: Sumedh S
authors.initials: SS
authors.lastname: Hoskote
authors.forename: Narender
authors.initials: N
authors.lastname: Annapureddy
authors.forename: Atul K
authors.initials: AK
authors.lastname: Ramesh
authors.forename: Keith
authors.initials: K
authors.lastname: Rose
authors.forename: James P
authors.initials: JP
authors.lastname: Jones
mesh_terms: D000212:Acyclovir / Q000009:adverse effects* / Q000031:analogs & derivatives*; D000998:Antiviral Agents / Q000009:adverse effects*; D006562:Herpes Zoster / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D020258:Neurotoxicity Syndromes / Q000209:etiology*; D013226:Status Epilepticus / Q000139:chemically induced*; D000077483:Valacyclovir; D014633:Valine / Q000009:adverse effects / Q000031:analogs & derivatives*
chemical_list: D000998:Antiviral Agents; D014633:Valine; D000077483:Valacyclovir; D000212:Acyclovir