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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 50, Num. 1, 2002, pp. 109-110

Neurology India, Vol. 50, No. 1, March, 2002, pp. 109-110

Acyclovir Induced Extrapyramidal Symptoms : Letter to Editor

S.K. Handa, C.P. Das, S. Prabhakar

Postgraduate Institute of Medical Education and Research, Chandigarh - 1600 12, India.

Code Number: ni02033

Acyclovir is usually a well tolerated antiherpetic agent. Vomiting and hypotension after intravenous administration and, occasionally, non-oliguric renal failure in dehydrated patients, are well known side effects.1-4 Confusion, hallucinations, seizures and coma are much rarer and have been reported in immunocompromised patients.4 Since there is a wide overlap of serum concentrations in patients with and without neurologic side effects, the relation between central nervous system effects and acyclovir serum concentrations remains unclear. Most of the cases of neurotoxicity with acyclovir have been described either with intravenous formulation, with or without preexisting renal disease, or with oral acyclovir formulation with end stage renal disease.2,4-6 A case of neurotoxicity following orally administered acyclovir in a young healthy girl with herpes labialis is described here.

A 18 year old female developed rash over left angle of mouth. Tzank smear was positive for giant cells and suggested herpes virus infection. Acyclovir (oral) was started on the next day in a dose of 200 mg, five times per day. She developed dystonia of tongue within 24 hours. Dystonia was reported to have developed after two hours of last dose. She was given another dose again under supervision in the hospital on the same day. 50 minutes later she developed dystonic posturing of tongue. Other drugs given before acyclovir were amoxycillin and paracetamol. She had rash over left angle of mouth, upper lip and tip of nose on examination (Fig. 1). Systemic and neurologic examination was normal. Her blood urea (30 mg %), serum creatinine (0.7 mg %), serum sodium (137 meq/L), serum potassium (3.8 meq/L), urine and hemogram were normal. Acyclovir was stopped, and she was put on phenergan and diazepam for three days. She had no recurrence of extrapyramidal symptoms.

Frequency of reported CNS side effects in 24 patients with acyclovir toxicity according to Haefeli et al4 is given in the Table I. The common symptoms of acyclovir toxicity include mental status disorders and involuntary movements. All patients usually recover. In serious cases, hemodialysis hastens the rate of recovery.5 Patients with end stage renal disease may not recover with peritoneal dialysis. There are case reports of death due to acyclovir toxicity treated with peritoneal dialysis.3 With the exception of renal failure, no definite predisposing factors for neurotoxicity have been defined. Since the prevalance of severe infection is higher in immunocompromised patients, it is not surprising that most of the patients reported until now were transplant recipients or patients with tumors. The present case appears to be first of its kind in a otherwise healthy patient.

References

  1. Cohen SMZ, Minkove JA, Zebley JW et al : Severe but reversible neurotoxicity from acyclovir. Ann Int Med 1984; 100 : 920.
  2. Swan SK, Bennett WM : Oral acyclovir and neurotoxicity. Ann Int. Med 1989; III : 188
  3. Davenport A, Goel S, Mackenzie JC : Neurotoxicity of acyclovir in patients with end stage renal failure with continuous ambulatory peritoneal dialysis. Am J Kidney Diseases 1982; 20 : 647-649.
  4. Haefeli WE, Schoenenberger RA, Weiss P et al : Acyclovirinduced neurotoxicity : concentration - side effect relationship in acyclovir overdose. Am J Med 1993; 94 : 212- 215.
  5. Adair JC, Gold M, Bond RE : Acyclovir neurotoxicity : clinical experience and review of the literature. Southern Medical Journal 1984; 87 : 1227-1231.
  6. Stathoulopoulou F, Almond MK, Dhillon S et al : Clinical pharmacokinetics of oral acyclovir in patients on continuous ambulatory peritoneal dialysis. Nephron1986; 74 : 337-341.

Copyright 2002 - Neurology India. Also available online at http://www.neurologyindia.com


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