A 28-year-old man is hospitalized for fever, headache, and confusion. He does not use tobacco or illicit drugs and is monogamous with his wife. The patient's cerebrospinal fluid analysis reveals lymphocytic pleocytosis, and a PCR is positive for herpesvirus. The patient is treated with intravenous high-dose acyclovir. Fever and mental status gradually improve, but on the third day of hospitalization the patient's serum creatinine level increases to 3.4 mg/dL from a baseline of 0.9 mg/dL at admission. The observed finding could have been prevented by which of the following?

Question

A 28-year-old man is hospitalized for fever, headache, and confusion.  He does not use tobacco or illicit drugs and is monogamous with his wife.  The patient's cerebrospinal fluid analysis reveals lymphocytic pleocytosis, and a PCR is positive for herpesvirus.  The patient is treated with intravenous high-dose acyclovir.  Fever and mental status gradually improve, but on the third day of hospitalization the patient's serum creatinine level increases to 3.4 mg/dL from a baseline of 0.9 mg/dL at admission.  The observed finding could have been prevented by which of the following?

Quizplus · Accepted Answer

Eductional Objective: The acute elevation of this patient's serum creatinine on the third day of hospitalization is likely due to acyclovir nephrotoxicity, which occurs in 5%-10% of patients who receive the drug intravenously. Acyclovir is excreted principally in the urine via glomerular filtration and tubular secretion. When the acyclovir concentration in the collecting duct exceeds its solubility, crystallization, crystalluria, and renal tubular damage can occur. In most cases, this toxic complication is transient and can be prevented (as well as treated) with adequate hydration and a reduction in the rate of drug infusion.

A 28-Year-Old Man Is Hospitalized for Fever, Headache, and Confusion