Death Delusions and Myoclonus: Acyclovir Toxicity

Abstract

PRESENTATION The therapies we administer often have the potential to trigger severe adverse reactions; particularly in patients with compromised organ function. For that reason, it is essential to be familiar with clinical syndromes spurred by drug toxicity and to include them in the differential diagnosis. Recognition of a life-threatening reaction was crucial when a 65-year-old woman with end-stage renal disease presented with peculiar signs and symptoms. As an outpatient, she was diagnosed with a multidermatomal herpes zoster infection (Figure 1) and prescribed valacyclovir, 1 gram every 8 hours, with prednisone. The next day, the patient began to hallucinate, asking, “Who is going to die? Me or that guy?” In addition, she exhibited emotional lability and agitation. She was taken to an urgent care center, where it was determined that her symptoms were secondary to steroid-induced psychosis. The prednisone was discontinued. Yet, her neuropsychiatric symptoms worsened over the next 24 hours. Ultimately, she became less alert and was unable to respond appropriately to questions. She was brought to the emergency department for further evaluation.