Memon Waqas, Rose Emily K, Akram Ayesha, Simba Brian
Internal Medicine/Nephrology, Virginia Commonwealth University, Richmond, USA.
Internal Medicine, Virginia Commonwealth University, Richmond, USA.
Cureus. 2021 Feb 22;13(2):e13494. doi: 10.7759/cureus.13494.
There are a few cases of valacyclovir-associated neurotoxicity (VAN) reported. This case report documents a case of a 55-year-old male presenting with emotional lability or pseudobulbar affect as the predominant or sole manifestation of VAN. A failure to adjust valacyclovir's dose for herpes simplex infection in the setting of dialysis-dependent end-stage renal disease (ESRD) preceded VAN in this patient. The patient presented with involuntary and uncontrollable outbursts of emotion. Computerized tomography (CT) scan identified no underlying cause. A complete neurological examination with cognitive assessment was performed, with no abnormalities. He benefited from the use of aggressive peritoneal dialysis (PD) that was employed to enhance valacyclovir's clearance in this case of intractable VAN. On discharge, the patient was back to baseline mental function. Traumatic brain injury, neoplasm, vascular lesions, metabolic abnormality, neurological disease, herpetic encephalitis, and disorders of mood were ruled out. This led to the hypothesis of encephalopathy due to valacyclovir intoxication. Given that the clinical manifestations were related to ESRD, a dose-adjustment of valacyclovir is imperative in the setting of ESRD to prevent VAN. Our case presents important clinical variations. Firstly, our patient demonstrates that VAN may present with no focal neurological impairment, but pseudobulbar affect. Secondly, aggressive PD was useful in this case for the treatment of VAN as opposed to hemodialysis. We believe that it cleared valacyclovir resulting in the resolution of symptoms.
有几例关于伐昔洛韦相关神经毒性（VAN）的报道。本病例报告记录了一名55岁男性患者，其以情绪不稳定或假性延髓麻痹为VAN的主要或唯一表现。在该患者中，VAN发生之前，在依赖透析的终末期肾病（ESRD）情况下，未针对单纯疱疹感染调整伐昔洛韦剂量。患者出现不由自主且无法控制的情绪爆发。计算机断层扫描（CT）未发现潜在病因。进行了包括认知评估在内的全面神经系统检查，未发现异常。在这例难治性VAN中，积极的腹膜透析（PD）用于提高伐昔洛韦清除率，患者从中受益。出院时，患者精神功能恢复至基线水平。排除了创伤性脑损伤、肿瘤、血管病变、代谢异常、神经系统疾病、疱疹性脑炎和情绪障碍。由此提出了伐昔洛韦中毒性脑病的假说。鉴于临床表现与ESRD相关，在ESRD情况下必须调整伐昔洛韦剂量以预防VAN。我们的病例呈现出重要的临床差异。首先，我们的患者表明VAN可能不伴有局灶性神经功能损害，而是表现为假性延髓麻痹。其次，与血液透析不同，积极的PD在本病例中对治疗VAN有用。我们认为它清除了伐昔洛韦，从而使症状得到缓解。
