SHM Converge Scientific Abstract ePoster Gallery-From Rash to Encephalopathy, a Zoster Case Turns Sour

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This case report describes a 47-year-old man with end-stage renal disease on peritoneal dialysis who developed valacyclovir toxicity after being prescribed a standard herpes zoster dose that was not adjusted for renal failure. He presented with altered mental status, confusion, unclear speech, erratic behavior, and falls after taking five doses. In the emergency department, he was afebrile without meningeal signs, but his condition worsened to seizure-like activity, prompting ICU transfer. Imaging was unremarkable, EEG showed no seizures, and an acyclovir level on day 2 was elevated. Poison control recommended hemodialysis to enhance drug clearance. After two hemodialysis sessions, his mental status improved markedly, and he returned to baseline and was discharged.<br /><br />The discussion emphasizes that valacyclovir is a prodrug of acyclovir, which is primarily renally excreted. In patients with impaired kidney function, failure to adjust the dose can cause accumulation and neurotoxicity, including encephalopathy and seizures. Diagnosis is mainly clinical, since drug levels do not always correlate well with symptoms. The case highlights the importance of recognizing renal dosing requirements and obtaining a thorough medical history before prescribing medications.

Asset Subtitle

Hussein Mhanna

Meta Tag

Author List Ali Elsayed, Hussein Mhanna, Matthew Rivkin, Rasha Batarseh

Category Clinical Vignettes

Concept Valacyclovir

Concept Acyclovir

Concept Renal Excretion

Concept Neurotoxicity

Concept Renal Dose Adjustment

Concept Hemodialysis

Distinguished Non-Finalist

Presenter Organization Hackensack Meridian Health Mountainside Medical Center

Presenting Author Hussein Mhanna

Track Adult

Keywords

valacyclovir toxicity

end-stage renal disease

peritoneal dialysis

renal dose adjustment

acyclovir neurotoxicity

altered mental status

seizure-like activity

hemodialysis

herpes zoster

drug accumulation

Valacyclovir

Acyclovir

Renal Excretion

Neurotoxicity

Renal Dose Adjustment

Hemodialysis