Abstract: SA-PO962

Acyclovir Neurotoxicity Occurring in Two Patients on Peritoneal Dialysis with Varicella-Zoster Virus Encephalitis

Session Information

Category: Nephrology Education

  • 1302 Fellows and Residents Case Reports


  • Guo, Xunxi Susan, NYP/Cornell, New York, New York, United States
  • Srivatana, Vesh, The Rogosin Institute, New York, New York, United States

Acyclovir neurotoxicity which can have varying symptoms including agitation, delirium, myoclonus, and coma are known to appear more commonly in end-stage renal disease (ESRD) patients. The kidney is the major route for acyclovir elimination and in ESRD patients, hemodialysis (HD) eliminates an estimated 45% of the drug during a 3-hour treatment, however in continuous ambulatory peritoneal dialysis (CAPD) clearance is 22 times lower compared to HD. We report 2 cases of acyclovir neurotoxicity in peritoneal dialysis (PD) patients with varicella-zoster virus (VZV) encephalitis with improved mental status after transitioning to HD.


Case 1: A 56 year-old female with ESRD on CAPD for 3 months, recently started on valacyclovir for 2 days for herpes zoster opthalmicus presents with acute onset of confusion. She was started on IV Acyclovir upon admission. Cerebrospinal fluid (CSF) analysis showed 3,500 Varicella DNA copies/mL. Her encephalopathy worsened and neurological evaluation with EEG and MRI/MRA was unrevealing. On hospital day 4, she underwent HD with subsequent improved mental status. Acyclovir level was 3.1 mcg/mL pre-HD and none detected post-HD. She was treated with 2 weeks of IV Acyclovir and intermittent HD with return to normal mental status and transitioned back to CAPD at discharge. Case 2: A 50 year-old female with ESRD on automated PD for 6 years presents with worsening mental status in setting of zoster ophthalmicus and superimposed cellulitis. She had been on valacyclovir for 2 days and continued on IV Acyclovir. Her mental status quickly deteriorated, only grimacing to pain. CSF analysis showed 81,700 Varicella DNA copies/mL. Acyclovir level was 8.1 mcg/mL. On hospital day 3, she was started on HD. Her course was complicated by troponinemia, hypotension, and reduced ejection fraction attributed to VZV myocarditis and was briefly on continuous renal replacement therapy. Her mental status returned to baseline 5 days after start of HD. She completed a course of acyclovir and was transitioned back to PD at discharge.


We present two unique cases of acyclovir neurotoxicity in PD patients with VZV encephalitis. They highlight that acyclovir even at appropriate dosing can lead to toxic levels and neuropsychiatric effects in the PD population due to no appreciable clearance.