SHM Converge Scientific Abstract ePoster Gallery-When the Cure Clouds the Mind

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This case describes a 77-year-old woman with asthma, hyperlipidemia, and recurrent UTIs who presented with confusion and falls after starting valacyclovir for shingles three days earlier. Over the preceding day, her family noticed new tremors, dysarthria, and unusual behavior. On exam, she had a crusting right-sided T8–T10 dermatomal rash and was alert but slow to answer orientation questions, without focal neurologic deficits. Initial evaluation showed severe acute kidney injury with creatinine 7.84 mg/dL from a baseline of 0.9–1.1 mg/dL. Urinalysis, electrolytes, and non-contrast head CT were unremarkable, and renal ultrasound showed no hydronephrosis, though the kidneys were mildly echogenic.<br /><br />Valacyclovir was stopped on admission, and aggressive IV fluid resuscitation was started. A urinary catheter was placed for significant post-void residual. Her renal function steadily improved over the hospital course, along with her mental status. By hospital days 2–4, she was clinically improving, had good urine output, and lumbar puncture was considered but deferred because of improvement. By day 5, her mental status had returned to baseline, creatinine had decreased to 1.85 mg/dL, and she was discharged home.<br /><br />The case highlights rare valacyclovir-associated nephrotoxicity and neurotoxicity, which are more likely in older adults and patients with renal dysfunction. The mechanism is usually crystal nephropathy from acyclovir precipitation in renal tubules, leading to impaired clearance and accumulation of neurotoxic metabolites in the CNS. Symptoms often begin about three days after starting therapy. Most patients recover with supportive care and IV fluids; dialysis may be considered if kidney function does not improve. Valacyclovir toxicity should be considered in patients who develop acute kidney injury and altered mental status after antiviral therapy, once other causes have been excluded.

Asset Subtitle

Vineet Gupta

Meta Tag

Author List Lianne Chau, Rakesh Malhotra, Reid Sasaki, Shreya Benerjee, Vineet Gupta

Category Clinical Vignettes

Concept Valacyclovir

Concept Acute Kidney Injury

Concept Neurotoxicity

Concept Altered Mental Status

Concept Renal Clearance

Distinguished Non-Finalist

Presenter Organization University of California, San Diego (UCSD)

Presenting Author Vineet Gupta

Track Adult

Keywords

valacyclovir toxicity

nephrotoxicity

neurotoxicity

acute kidney injury

altered mental status

older adults

crystal nephropathy

acyclovir precipitation

shingles treatment

renal dysfunction

Valacyclovir

Acute Kidney Injury

Neurotoxicity

Altered Mental Status

Renal Clearance