World Journal of Clinical Cases...kidneys, patients with renal failure undergoing renal replacement therapy are prone to drug adverse effects and poisoning. Severe neurotoxicity caused

World Journal ofClinical Cases

World J Clin Cases 2019 October 26; 7(20): 3168-3383

ISSN 2307-8960 (online)

Published by Baishideng Publishing Group Inc

W J C C World Journal ofClinical CasesContents Semimonthly Volume 7 Number 20 October 26, 2019

OPINION REVIEW3168 Clinical use of low-dose aspirin for elders and sensitive subjects

Zhang Y, Fang XM, Chen GX

ORIGINAL ARTICLE

Retrospective Study

3175 Distribution and drug resistance of pathogenic bacteria in emergency patientsHuai W, Ma QB, Zheng JJ, Zhao Y, Zhai QR

3185 Comparative analysis of robotic vs laparoscopic radical hysterectomy for cervical cancerChen L, Liu LP, Wen N, Qiao X, Meng YG

3194 Feasibility of laparoscopic isolated caudate lobe resection for rare hepatic mesenchymal neoplasmsLi Y, Zeng KN, Ruan DY, Yao J, Yang Y, Chen GH, Wang GS

3202 Rh-incompatible hemolytic disease of the newborn in HefeiBi SH, Jiang LL, Dai LY, Zheng H, Zhang J, Wang LL, Wang C, Jiang Q, Liu Y, Zhang YL, Wang J, Zhu C, Liu GH, Teng RJ

3208 Soft tissue release combined with joint-sparing osteotomy for treatment of cavovarus foot deformity in older

children: Analysis of 21 casesChen ZY, Wu ZY, An YH, Dong LF, He J, Chen R

Observational Study

3217 Clinical characteristics of sentinel polyps and their correlation with proximal colon cancer: A retrospective

observational studyWang M, Lu JJ, Kong WJ, Kang XJ, Gao F

Prospective Study

3226 Longitudinal observation of intraocular pressure variations with acute altitude changesXie Y, Sun YX, Han Y, Yang DY, Yang YQ, Cao K, Li SN, Li X, Lu XX, Wu SZ, Wang NL

Randomized Controlled Trial

3237 Combination of propofol and dezocine to improve safety and efficacy of anesthesia for gastroscopy and

colonoscopy in adults: A randomized, double-blind, controlled trialLi XT, Ma CQ, Qi SH, Zhang LM

WJCC https://www.wjgnet.com October 26, 2019 Volume 7 Issue 20I

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ContentsWorld Journal of Clinical Cases

Volume 7 Number 20 October 26, 2019

META-ANALYSIS3247 Prognostic significance of malignant ascites in gastric cancer patients with peritoneal metastasis: A systemic

review and meta-analysisZheng LN, Wen F, Xu P, Zhang S

CASE REPORT3259 Gonadotrophin-releasing hormone agonist-induced pituitary adenoma apoplexy and casual finding of a

parathyroid carcinoma: A case report and review of literatureTriviño V, Fidalgo O, Juane A, Pombo J, Cordido F

3267 Constrictive pericarditis as a cause of refractory ascites after liver transplantation: A case reportBezjak M, Kocman B, Jadrijević S, Gašparović H, Mrzljak A, Kanižaj TF, Vujanić D, Bubalo T, Mikulić D

3271 Endoluminal closure of an unrecognized penetrating stab wound of the duodenum with endoscopic band

ligation: A case reportKim DH, Choi H, Kim KB, Yun HY, Han JH

3276 Spontaneous superior mesenteric artery dissection following upper gastrointestinal panendoscopy: A case

report and literature reviewOu Yang CM, Yen YT, Chua CH, Wu CC, Chu KE, Hung TI

3282 Hepatic amyloidosis leading to hepatic venular occlusive disease and Budd-Chiari syndrome: A case reportLi TT, Wu YF, Liu FQ, He FL

3296 De Winter syndrome and ST-segment elevation myocardial infarction can evolve into one another: Report of

two casesLin YY, Wen YD, Wu GL, Xu XD

3303 Next generation sequencing reveals co-existence of hereditary spherocytosis and Dubin–Johnson syndrome

in a Chinese gril: A case reportLi Y, Li Y, Yang Y, Yang WR, Li JP, Peng GX, Song L, Fan HH, Ye L, Xiong YZ, Wu ZJ, Zhou K, Zhao X, Jing LP, Zhang FK,

Zhang L

3310 Recognizable type of pituitary, heart, kidney and skeletal dysplasia mostly caused by SEMA3A mutation: A

case reportHu F, Sun L

3322 Repeated lumps and infections: A case report on breast augmentation complicationsZhang MX, Li SY, Xu LL, Zhao BW, Cai XY, Wang GL

3329 Severe mental disorders following anti-retroviral treatment in a patient on peritoneal dialysis: A case report

and literature reviewHe QE, Xia M, Ying GH, He XL, Chen JH, Yang Y

WJCC https://www.wjgnet.com October 26, 2019 Volume 7 Issue 20II



3335 Fish bone-induced myocardial injury leading to a misdiagnosis of acute myocardial infarction: A case reportWang QQ, Hu Y, Zhu LF, Zhu WJ, Shen P

3341 Potentially fatal electrolyte imbalance caused by severe hydrofluoric acid burns combined with inhalation

injury: A case reportFang H, Wang GY, Wang X, He F, Su JD

3347 Ureter - an unusual site of breast cancer metastasis: A case reportZhou ZH, Sun LJ, Zhang GM

3353 Alternative technique to save ischemic bowel segment in management of neonatal short bowel syndrome: A

case reportGeng L, Zhou L, Ding GJ, Xu XL, Wu YM, Liu JJ, Fu TL

3358 Sister Mary Joseph’s nodule in endometrial carcinoma: A case reportLi Y, Guo P, Wang B, Jia YT

3364 Synchronous quadruple primary malignancies of the cervix, endometrium, ovary, and stomach in a single

patient: A case report and review of literatureWang DD, Yang Q

3372 Ureteral Ewing’s sarcoma in an elderly woman: A case reportLi XX, Bi JB

3377 Anaplastic lymphoma kinase-negative anaplastic large cell lymphoma masquerading as Behcet's disease: A

case report and review of literatureLuo J, Jiang YH, Lei Z, Miao YL

WJCC https://www.wjgnet.com October 26, 2019 Volume 7 Issue 20III



ABOUT COVER Editorial Board Member of World Journal of Clinical Cases, Faycal Lakhdar,MD, Professor, Department of Neurosurgery, University Hospital Center ofFes, University Sidi Mohammed Ben Abdellah, FES 10000, Morocco

AIMS AND SCOPE The primary aim of World Journal of Clinical Cases (WJCC, World J Clin Cases)is to provide scholars and readers from various fields of clinical medicinewith a platform to publish high-quality clinical research articles andcommunicate their research findings online. WJCC mainly publishes articles reporting research results and findingsobtained in the field of clinical medicine and covering a wide range oftopics, including case control studies, retrospective cohort studies,retrospective studies, clinical trials studies, observational studies,prospective studies, randomized controlled trials, randomized clinicaltrials, systematic reviews, meta-analysis, and case reports.

INDEXING/ABSTRACTING The WJCC is now indexed in PubMed, PubMed Central, Science Citation IndexExpanded (also known as SciSearch®), and Journal Citation Reports/Science Edition.The 2019 Edition of Journal Citation Reports cites the 2018 impact factor for WJCCas 1.153 (5-year impact factor: N/A), ranking WJCC as 99 among 160 journals inMedicine, General and Internal (quartile in category Q3).

RESPONSIBLE EDITORS FORTHIS ISSUE

Responsible Electronic Editor: Ji-Hong Liu

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NAME OF JOURNALWorld Journal of Clinical Cases

ISSNISSN 2307-8960 (online)

LAUNCH DATEApril 16, 2013

FREQUENCYSemimonthly

EDITORS-IN-CHIEFDennis A Bloomfield, Bao-Gan Peng, Sandro Vento

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PUBLICATION DATEOctober 26, 2019

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W J C C World Journal ofClinical CasesSubmit a Manuscript: https://www.f6publishing.com World J Clin Cases 2019 October 26; 7(20): 3329-3334

DOI: 10.12998/wjcc.v7.i20.3329 ISSN 2307-8960 (online)

CASE REPORT

Severe mental disorders following anti-retroviral treatment in apatient on peritoneal dialysis: A case report and literature review

Qi-En He, Min Xia, Guang-Hui Ying, Xue-Lin He, Jiang-Hua Chen, Yi Yang

ORCID number: Qi-En He(0000-0002-4189-0519); Min Xia(0000-0001-8554-9913); Guang-HuiYing (0000-0002-0522-1676); Xue-Lin He (0000-0001-9301-3705); Jiang-Hua Chen (0000-0002-9539-000X); YiYang (0000-0002-6285-0807).

Author contributions: Yang Yperformed the investigation andprovided resources for the casecare and report; Xia M, Ying GHcollected the patient’s clinical data;He XL analyzed data; He QE wrotethe first draft of the article; ChenJH and Yang Y reviewed andedited the article for importantintellectual content.

Supported by the grant from theNational Nature ScienceFoundation of China, No.81670621; and the Nature ScienceFoundation of Zhejiang Province,No. LY16H050001.

Informed consent statement:Consent was obtained fromrelatives of the patient forpublication of this report and anyaccompanying images.

Conflict-of-interest statement: Theauthors declare that they have noconflicts of interest.

CARE Checklist (2016) statement:The authors have read the CAREChecklist (2016), and themanuscript was prepared andrevised according to the CAREChecklist (2016).

Open-Access: This article is anopen-access article which wasselected by an in-house editor andfully peer-reviewed by externalreviewers. It is distributed in

Qi-En He, Xue-Lin He, Jiang-Hua Chen, Yi Yang, Kidney Disease Center, the First AffiliatedHospital, College of Medicine, Zhejiang University, Key Laboratory of Kidney DiseasePrevention and Control Technology, Zhejiang Province, the Third Grade Laboratory Under theNational State, Administration of Traditional Chinese Medicine, Hangzhou 310000, ZhejiangProvince, China

Qi-En He, Min Xia, Guang-Hui Ying, Xue-Lin He, Department of Nephrology, Beilun People'sHospital, Ningbo 315000, Zhejiang Province, China

Corresponding author: Yi Yang, MD, Doctor, Kidney Disease Center, the First AffiliatedHospital, College of Medicine, Zhejiang University, Key Laboratory of Kidney DiseasePrevention and Control Technology, Zhejiang Province; the Third Grade Laboratory under theNational State, Administration of Traditional Chinese Medicine, Hangzhou 310000, ZhejiangProvince, China. [email protected]:+86-571-87236992

AbstractBACKGROUNDAntiviral drugs are widely used in populations with viral infection caused byimmunologic inadequacy. Because these drugs are mainly metabolized by thekidneys, patients with renal failure undergoing renal replacement therapy areprone to drug adverse effects and poisoning. Severe neurotoxicity caused byantiviral drugs is a rare but life-threatening complication.

CASE SUMMARYThis study reported one male patient on peritoneal dialysis who suffered fromsevere mental disorders after receiving an overdose of acyclovir and valacyclovirfor the treatment of herpes zoster. The literature review suggested thathemodialysis is better than peritoneal dialysis to clear acyclovir from thecirculation. The patient died after his consciousness deteriorated despiteperitoneal dialysis and continuous blood purification.

CONCLUSIONThis case emphasizes cautiousness when using anti-retroviral drugs in patientswith uremia. Hemodialysis is optimal method to remove the drugs.

Key words: Chronic renal failure; Peritoneal dialysis; Acyclovir; Valacyclovir;Neurotoxicity; Herpes zoster; Case report

©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.

WJCC https://www.wjgnet.com October 26, 2019 Volume 7 Issue 203329

https://www.wjgnet.comhttps://dx.doi.org/10.12998/wjcc.v7.i20.3329http://orcid.org/0000-0002-4189-0519http://orcid.org/0000-0001-8554-9913http://orcid.org/0000-0002-0522-1676http://orcid.org/0000-0001-9301-3705http://orcid.org/0000-0002-9539-000Xhttp://orcid.org/0000-0002-6285-0807mailto:[email protected]

accordance with the CreativeCommons Attribution NonCommercial (CC BY-NC 4.0)license, which permits others todistribute, remix, adapt, buildupon this work non-commercially,and license their derivative workson different terms, provided theoriginal work is properly cited andthe use is non-commercial. See:http://creativecommons.org/licenses/by-nc/4.0/

Manuscript source: Unsolicitedmanuscript

Received: May 29, 2019Peer-review started: June 4, 2019First decision: August 1, 2019Revised: August 23, 2019Accepted: September 11, 2019Article in press: September 11, 2019Published online: October 26, 2019

P-Reviewer: Hatipoglu SS-Editor: Wang JLL-Editor: Ma JYE-Editor: Qi LL

Core tip: A patient on peritoneal dialysis who received an overdose of anti-virals showedsevere mental disorders. Peritoneal dialysis and continuous renal replacement therapydid not improve the symptoms. Hemodialysis is recommended to remove excess drugs.

Citation: He QE, Xia M, Ying GH, He XL, Chen JH, Yang Y. Severe mental disordersfollowing anti-retroviral treatment in a patient on peritoneal dialysis: A case report andliterature review. World J Clin Cases 2019; 7(20): 3329-3334URL: https://www.wjgnet.com/2307-8960/full/v7/i20/3329.htmDOI: https://dx.doi.org/10.12998/wjcc.v7.i20.3329

INTRODUCTIONHerpes zoster occurs upon reactivation of varicella zoster virus and is characterizedby pain and blistering skin eruption with dermatomal distribution[1-4]. The occurrenceof herpes zoster increases with decline in T-cell-mediated immunity, which may occurwith age or immunosuppression[1-4]. The rash typically resolves in 2-4 wk, but nervepain may continue for months to years[1,3]. Beside pain management, anti-retroviraldrugs can be used in patients without response to topical anti-retroviral, age ≥ 50years, moderate to severe pain, severe rash, and/or non-truncal involvement[2,4]. Thecommon drugs include valacyclovir, acyclovir, foscarnet, and bruvudin[2]. Comparedwith acyclovir, valacyclovir has advantages such as better oral effectiveness andtolerance, high water solubility, and less adverse reactions. Valacyclovir rapidlytransforms into acyclovir after entering the body. Its common side effects includenausea, vomiting, and discomfort[5].

One possible, albeit rare, side effect of anti-retroviral drugs is central nervoussystem toxicity, which has been described since the 1980s[6-9]. The symptoms inpatients with previously normal brain function may include visual hallucinations,death delusion, tremor, and coma, with onset of 24-72 h after starting acyclovir[8]. Thesymptoms are possibly due to a metabolite of acyclovir that is found at high levels inthe cerebrospinal fluid of patients with neuropsychiatric symptoms[10]. Since 90% ofacyclovir is cleared by the kidneys, patients with chronic kidney disease haveincreased serum half-life of acyclovir[11]. Most patients with neuropsychiatricdisorders under acyclovir treatment have renal function impairment[10].

We present one patient on peritoneal dialysis who suffered from severe mentaldisorders after taking an overdose of antiviral drugs for herpes zoster. The patientdied after his consciousness did not improve after peritoneal dialysis and continuousblood purification.

CASE PRESENTATION

Chief complaintsA 65-year-old man on peritoneal dialysis was referred to our hospital in July 2018with complaints of blisters on the left frontal area with pain, and unstable walkingand hallucinations.

History of present illnessThe patient felt severe pain in the left frontal face, with blisters for 6 d, and wasdiagnosed with herpes zoster. He was given antiviral treatment with intravenousacyclovir 0.5 g qd and dexamethasone 5 mg qd to relieve pain (continuous treatmentfor 3 d). The dermatologist prescribed oral valacyclovir 0.3 g bid after 3 d.Nonetheless, the patient misunderstood the recommendation, and received acyclovirand valacyclovir simultaneously. After 2 d of treatment, the local facial pain wasrelieved, and the blisters became stable, but he became with unstable walking andinvoluntary shaking of the limbs, accompanied by hallucinations (irregular flutteringof objects when the eyes were closed), irritability, and lethargy. He denied fever, lossof consciousness, epilepsy, suicidal or homicidal ideation, and a sudden stop ofdialysis. Before onset, the patient had mild temperament and took care of himself inthe daily life.

History of past illnessThe patient had a history of hypertension for more than 10 years, under control using


He QE et al. Mental disorders after anti-retroviral

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http://creativecommons.org/licenses/by-nc/4.0/http://creativecommons.org/licenses/by-nc/4.0/

nifedipine controlled release tablets 30 mg bid and valsartan 80 mg bid.He was diagnosed with idiopathic chronic renal failure (stage 5). He had been

receiving peritoneal dialysis treatment for 3 years. He was anuretic at admission usingperitoneal dialysis solution with 2.5% calcium glucose 2000 mL × 4 bags, continuousambulatory peritoneal dialysis (CAPD), with an ultrafiltration of 1200 mL/d.

Personal and family historyThe patient denied any personal or family history of diseases.

Physical examination upon admissionOn admission, the body temperature 37.2 °C, pulse 107 bpm, breathing 20/min, bloodpressure 175/108 mmHg, intermittent mild disturbance of consciousness, and withvisible scattered red blister rash in the left eyelid and left forehead, which wasprotruded and tender, but otherwise with normal superficial lymph nodes andcardiopulmonary examinations. Nervous system examination showed negative Pap'ssign but normal muscle tension in limbs.

Laboratory examinationsThe laboratory examinations showed: White blood cells 7.8 × 109/L, hemoglobin 86g/L, albumin 28 g/L, creatinine 1146 µmol/L, urea nitrogen 21.6 mmol/L, uric acid277 µmol/L, potassium 4.2 mmol/L, sodium 145 mmol/ L, chlorine 100 mmol/L, PO243 mmHg, TCO2 24 mmol/L, glucose 4.7 mmol/L, and iPTH 313 pg/mL. Dialysisadequacy: KT/V = 1.64 (1 mo ago), Ccr= 41.4 L/wk. The electrocardiogram showednormal sinus rhythm. The lumbar puncture showed: Cerebrospinal fluid pressure 155mmH2O, proteins 542 mg/L, glucose 4.64 mmol/L, chlorine 121.7 mmol/L (noabnormality), and negative bacteria and tuberculosis.

Imaging examinationsThere were no obvious abnormalities in head and chest computed tomography (CT)as well as head magnetic resonance imaging (MRI).

FINAL DIAGNOSISBased on the laboratory test results and imaging examinations, the differentialdiagnoses of cerebrovascular accidents, viral encephalitis and uremia encephalopathywere ruled out. Since he had a clear history of overdose of antiviral drugs 6 days priorto the onset of the psychiatric symptoms, the patient was finally diagnosed as mentaldisorders caused by antiviral drugs.

TREATMENTImmediately after admission, valacyclovir was discontinued, the peritoneal fluid wasincreased to 5 bags/d, 2000 mL per bag, and CAPD mode, and the blood pressure wasdropped to around 150-160/90 mmHg after antihypertensive treatment with Adalat30 mg bid, valsartan 80 mg bid and perindopril 8 mg qd. After 2 d of treatment, theinvoluntary limb shaking was not relieved and the disturbance of consciousnessprogressively aggravated (drowsiness-delirium-coma). On the third day afteradmission (July 31, 2018), the patient's respiratory failure worsened, blood gasanalysis showed: pH 7.18, PO2 81 mmHg (oxygen), and PaCO2 77 mmHg, revealingcarbon dioxide retention and type 2 respiratory failure. After intubation andrespiratory support, the patient was transferred to the intensive care unit (ICU) on thefourth day after admission. In the ICU, peritoneal dialysis was discontinued andcontinuous renal replacement therapy (CRRT) was started.

OUTCOME AND FOLLOW-UPThough given positive rescue treatment, the patient’s consciousness was notimproved. The patient died 6 d after admission.

DISCUSSIONHerpes zoster usually develops in patients with compromised immune function.Patients on dialysis are at high risk of Herpes zoster. Both valacyclovir and acyclovir



3331

are considered to have strong inhibitory effects on types 1 and 2 herpes virus andvaricella herpes virus[12]. Valacyclovir is a precursor of acyclovir, which is converted toacyclovir by the liver. Compared with acyclovir, it has the advantages of higherabsorption rate, more better pharmacokinetics and pharmacodynamics, and lowerfrequency of use[5].

The neurotoxicity of acyclovir was reported as early as the 1980s[6-9]. The clinicalmanifestations include consciousness disorders and hallucinations, fantasy, insomnia,photoallergies, dysarthria, paresthesia, and coma[13-17]. If uremia patients developneuropsychiatric symptoms during anti-retroviral treatment, it is especially importantto promptly identify and discontinue the suspicious drugs. Clinicians tend tooverlook drug-induced neuropsychiatric disorders. The patient had a history ofexcessive use of antiviral drugs and showed obvious neuropsychiatric symptoms,despite normal head CT and MRI, and lumbar puncture and cerebrospinal fluidexamination. In the present report, the patient had limb shaking, visualhallucinations, and severe disturbances of consciousness, and these symptomsprogressively aggravated, which is very rare.

Valacyclovir-associated neurotoxicity usually occurs within 48-72 h of treatmentstart, and the symptoms can be gradually relieved after the drug is discontinued for 4-14 d (Table 1). For the patient in the present study, the time of onset and duration ofsymptoms were similar to those reported in literature[14,16-25] (Table 1).

Since acyclovir is mainly cleared by the kidneys, it is a consensus to reduce its dosein patients with renal failure[25]. The dose is mainly determined by a combination offactors such as different methods of dialysis, residual renal function, hydration, andage. The dose of drug used in many cases of neurotoxicity is often greater than therecommended dose[11,24]. It is generally believed that a concentration of acyclovir of2.5-4.5 µg/mL[26] or a concentration of its main metabolite, carboxymethoxymethylguanine, above 10.8 µmol/L[10] in plasma leads to neurotoxicity. Nevertheless,there is still no consensus on the specific numerical reference range of therapeutic andtoxic doses of such drugs, and it is difficult to measure the drug levels in clinicalpractice.

In the case reported here, increasing the dose of peritoneal dialysis and retentiontime still could not alleviate the clinical symptoms. Acyclovir and valacyclovir areboth soluble and low-protein-bound drugs. In terms of the effectiveness ofvalacyclovir, a single hemodialysis for 6 h can remove about 60% of the drug, while itis considered to have poor clearance by peritoneal dialysis. On the other hand, casereports suggested that peritoneal dialysis with continuous perfusion of super-doseperitoneal dialysis solution can promote the clearance of valacyclovir[13,21,24,27]. Studieshave shown that in patients with normal renal function, 89% of valacyclovir can becleared from the urine in the form of acyclovir after 2.5-3.3 h, while the half-life of thedrug is extended to 14-20 h in patients receiving CAPD for uremia (4 × 2 L exchangedose), and only 5.27 mL/min (0.355 L/h/1.73 m2) can be cleared by peritonealdialysis[21,27]. After a 6-h hemodialysis, the hemodialysis clearance rate of acyclovir isup to 113 mL/min and the plasma drug concentration can be reduced by 61.6%.Therefore, hemodialysis is at least 20 times better than peritoneal dialysis in terms ofclearance effect. Based on the large differences in clearance rates between the twodialysis methods, it is suggested to switch peritoneal dialysis to hemodialysis toincrease the effect of drug clearance[20,24,28]. Nevertheless, when neurotoxicity occurs,the expected improvement of neurotoxicity by hemodialysis may be delayed, even fora few days. Kageyama et al[29] reported a 75-year-old hemodialysis male whopresented with hallucinations, dysarthria, and psychotic symptoms after intravenousacyclovir with reduced dose, which further indicates that the dose adjustment of thesedrugs is difficult and needs to be comprehensively individualized. CRRT has a goodeffect on clearing drugs with middle-and-large molecular weight or high proteinbinding rate. Meanwhile, valacyclovir and acyclovir are soluble and have a lowprotein binding rate, but there is a lack of literature on the efficacy of CRRT inclearing acyclovir and valacyclovir.

CONCLUSIONIn summary, clinicians need to be extra cautious when applying antiviral drugs inpatients with renal failure. They need to be alert to the possible seriousneuropsychiatric symptoms, need to adjust dose according to the level of renalfunction, pay attention to treatment course and hydration, be fully aware of thepossible neurotoxicity caused by these drugs, and be aware of the good prognosisafter early identification and active intervention. In the meantime, since the clearancerate of these drugs is low when using peritoneal dialysis, these patients should be



3332

Table 1 The reported cases of acyclovir/valacyclovir neurotoxicity in the literature

Author Year ofpublication

Patient Stage ofCKD

Renalreplacementmanner

Dosage(mg/d)

Duration ofantiviraltreatment

Concomi-tantmedication

Neuropsy-chiatricsymptoms

Outcomesex/age

Pipili et al[18] 2013 Female/72 ESRD PD Valacyclovirtablets 3 gdaily for 3 d

3 d Nifedipine,irbesartan,cinacalcet,atorvastatin,alfacalcidol

Confusionand visualhallucinations

3 d, restoredafter PD 6 × 2L per day

Chaudhari etal[16]

2014 Male/66 ESRD PD Oralvalacyclovir1000 mg dailyfor 7 d

7 d Simvastatin,metoprolol,sevelamer,furosemide,andglimepiride

Hallucination,insomnia, andphotosensi-tivity

7 d, improvedafter regularregimen andhydration

Asahi et al[17] 2009 Female/78 Withoutpreviousrenal failure

NO Valacyclovir3000 mg/d

6 d Notmentioned

Unconsciou-sness

5 d, recovered14 d later

Asahi et al[17] 2009 Male/73 ESRD Hemodialysis Valacyclovir3000 mg/d

2 d Notmentioned

Confusion,hallucination

2 d,completelyrecovered 3 dlater

Singh et al[19] 2014 Female/58 ESRD HD Valacyclovir500 mg/d

2 d Notmentioned

Alteredsensorium,irritability,drowsiness,confusion

2 d,completelyrecovered 5 dlater

Kambham-pati et al[20]

2011 Female/49 ESRD Maintenancehemodialysis

Valacyclovir1000 mg threetimes a day

2 d Notmentioned

Disoriented,confused,agitated,hallucinating,delirious,incoherent

1 d, 4000 mg,completelyrecoveredafter secondsession ofhemodialysis

Prasad etal[14]

2017 Female/57 ESRD PD 1000mg threetimes per dayofvalacyclovir

3 d Notmentioned

Confusionand alteredsensorium

1 day,completelyrecovered 24hlater

Izzedine etal[21]

2001 Female/60 ESRD PD Valacyclovir500 mg daily

Reduced 500mg ofvalacyclovirevery 2 d

Notmentioned

Disorientatedwith ocularand auditoryhallucinationsand loss ofdecorumwithouttorpor orcoma.

3 d, recovered48 h later

Strumia etal[22]

2004 Male/81 ESRD Hemodialysis Oralvalacyclovir1000 mgevery 8 h thenintravenousacyclovir infull dosage

3 d Notmentioned

Visualhallucination,confusion anddisorientation

3 daysdcompletelyrecovered 6 dlater

Linssen-Schuurmanset al[23]

1998 Male/58 CKD Intermittenthemodialysistwice a week

Valacyclovir 3g/d

2 d Notmentioned

Dizziness,hallucinations, loss ofdecorum,disoriented,slurredspeech

1 d, completerecovery

Takayanagiet al[24]

2010 Male/67 ESRD PD Valacyclovir,1 g/d

5 d Notmentioned

Hallucina-tions


Sadjadi etal[25]

2018 Male/80 ESRD PD Acyclovir 5mg/kgintravenously, followed byoral acyclobir400 mg/d

3 d Notmentioned

Confusion,delusion,disorientation, restlessness,visualhallucinations, seizures


CKD: Chronic kidney disease; ESRD: End-stage renal disease; PD: Peritoneal dialysis.



3333

switched to hemodialysis.

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