Case Reports
Sunday, October 13, 2024
12:45 PM–02:15 PM
Abstract
Introduction:
Acyclovir-induced neurotoxicity is widely reported, however there are scant reports on its subsequent thromboembolic events. A case of acute stroke compounded by acyclovir-induced neurotoxicity in a patient with kidney failure is described.
Case:
A 76-year-old Southeast Asian female with kidney failure who survived 10 years on hemodialysis, presented to the emergency department (ED) with lethargy, headache, dizziness and sudden onset expressive aphasia. Medical history included hypertension, diabetes, dyslipidemia, hypothyroidism and ischemic heart disease; all medically managed. After 48 hours in ED where hemodialysis was twice performed, she was transferred to the ward. Upon admission, she was alert with scanning speech. Further deterioration of muscle tone, power and reflexes warranted an urgent MRI which revealed acute infarct with DWI-FLAIR mismatch in mid-brain. Subsequently, physical examination identified herpes zoster rash on the head and neck. It was then discovered that four days earlier she was prescribed oral acyclovir 800mg five times daily; after 16 doses, she developed headache, lethargy and dizziness, which progressed to scanning dysarthria and visual hallucinations by day four. Symptoms returned to baseline after four further cycles of hemodialysis.
Discussion:
Post-acyclovir ingestion, the symptoms suggested neurotoxicity secondary to renally-unadjusted dose. Stopping acyclovir and symptoms improvement post-hemodialysis supported this iatrogenic neurotoxicity. The patient’s age, medical history and presenting symptoms pointed towards a diagnosis of stroke, confirmed by MRI, which could be compounded by the acyclovir-induced neurotoxicity. Investment in an integrated patient information system for seamless transfer of care is pertinent, e.g. alerting practitioners of different departments to underlying condition to aid prescribing decisions. A thorough medication history and physical examination, and availability of acyclovir blood level rapid testing could initiate earlier interventions.
Conclusion:
In patients with kidney failure, care is required when prescribing acyclovir and monitoring for neurotoxicity is pertinent to identify the early signs of stroke.
Presenting Author
Vijitha Rajendran M.Clin.Pharm.HOSPITAL SEBERANG JAYA
Authors
Boon Huei Kong MRCP
Hospital Seberang Jaya
Mohamed Azlam Mohamed Micdhadhu MRCP
HOSPITAL SEBERANG JAYA
Gillian Phua MPharm,PhD
Swansea University Medical School