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A case of acyclovir neurotoxicity presenting with atypical cerebrospinal fluid findings
  1. Guramrinder Singh Thind,
  2. Richard Roach
  1. Internal Medicine, Western Michigan University School of Medicine, Kalamazoo, Michigan, USA
  1. Correspondence to Dr Guramrinder Singh Thind, guramrinder.thind{at}


An 82-year-old man with a history of end-stage renal disease presented with progressively worsening confusion and somnolence for the past 4–5 days. The patient was diagnosed with herpes zoster by his primary care physician 5 days ago and was started on a course of valacyclovir 1 g three times a day (dose not adjusted for renal impairment).

A lumbar puncture was performed and cerebrospinal fluid (CSF) studies revealed 37 white blood cells (WBCs)/hpf (100% monocytes), protein 64 mg/dL and glucose 52 mg/dL. He was started on ceftriaxone, ampicillin and acyclovir. MRI of the brain was done and was unremarkable. Acyclovir-induced encephalopathy was high on differential, but his CSF findings were concerning for viral encephalitis. Nonetheless, all antimicrobials were discontinued and he was scheduled for a 5-hour dialysis session. The very next day, he showed immense improvement and eventually recovered completely. CSF PCR tests for both herpes simplex virus and varicella zoster virus came back negative.

  • Unwanted effects / adverse reactions
  • Drugs: infectious diseases
  • Infection (neurology)
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  • Contributors Both authors contributed to the manuscript as follows. RR was part of the primary team who admitted the patient and GST was on the Infectious Disease team, which was consulted for the patient at that time. Hence, both authors were directly involved with patient care. GST did the literature review and manuscript write-up. RR supervised and revised critically for important intellectual content. Both authors gave their final approval of the version to be published.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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