A female, 65 years old; patient was admitted to the hospital on March 30, 2022 due to topulmonary infection. The patient had a history of diabetes, hypertension, and old cerebral infarction for 8 years, and had no impairment in physical activity or language communication; she has a stage 5 chronic kidney disease with regular hemodialysis and is allergic to "synergistic sulfonate tablets". After admission, she was given moxifloxacin and piperacillin sodium and sulbactam sodium to treat pulmo-nary infection. On April 5, she started to take valaciclovir dispersive tablets and loprofendein sustained release tablets. On April 8, she developed speech impairment. Improved head CT and MRI examination showed no cerebral hemorrhage and new cerebral infarction. The symptoms worsened on April 9, and she developed cognitive impairment and drowsiness, which was considered to be related to valaciclovir. Valaciclovir was stopped on April 10, and the patient was discharged from hospital with improved neu-rological symptoms after multiple hemodialysis. According to the Naranjo Causality Evaluation Scale of adverse reactions, the association between this adverse reaction and valaciclovir was evaluated as probable. The concentration of main metabolites of valaciclovir was correlated with its neurotoxicity. When this adverse reaction occurs clinically, the suspected drug should be stopped at first. If necessary, peritoneal dialysis or hemodialysis can promote the excretion of the drug.

1.Lam NN, Weir MA, Yao Z, et al. Risk of acute kidney injury from oral acyclovir: a population-based study[J]. Am J Kidney Dis, 2013, 61(5): 723-729. DOI: 10.1053/j.ajkd.2012.12.008.

2.Tilson HH, Engle CR, Andrews EB. Safety of acyclovir: a summary of the first 10 years experience[J]. J Med Virol, 1993, Suppl 1: 67-73. DOI: 10.1002/jmv.1890410513.

3.Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reac-tions[J]. Clin Pharmacol Ther, 1981, 30(2): 239-245. DOI: 10.1038/clpt.1981.154.

4.王冬雪, 徐锋, 侯继秋. 伐昔洛韦片致血液透析患者脑病1例[J].中国药物应用与监测, 2019, 16(3): 181-182. [Wang DX, Xu F, Hou JQ. Encephalopathy caused by valaciclovir tablets in a hemodialysis patient[J]. Chinese Journal of Drug Application and Monitoring, 2019, 16(3): 181-182.] DOI: 10.3969/j.issn.1672-8157.2019.03.015

5.唐晓霞, 朱雯雯, 陈大奎, 等. 伐昔洛韦片致老年血液透析患者严重精神异常1例[J].药物流行病学杂志, 2013, 22(9): 523-524. [Tang XX, Zhu WW, Chen DK, et al. Valaciclovir tablets induced severe mental abnormality in elderly hemodialysis patients[J]. Chinese Journal of Pharmacoepidemiology, 2013, 22(9): 523-524.] DOI: CNKI:SUN:YWLX.0.2013-09-024.

6.吉俊, 王一梅, 沈子妍, 等. 伐昔洛韦致腹膜透析患者严重神经毒性一例[J]. 中华肾脏病杂志, 2018, 34(3): 218-219. [Ji J, Wang YM, Shen ZY, et al. Valaciclovir induced severe neurotoxicity in peritoneal dialysis patients [J]. Chinese Journal of Nephrology, 2018, 34(3): 218-219.] DOI: 10.3760/cma.j.issn.1001-7097. 2018.03.010.

7.段小军, 谈平, 曾翠青. 伐昔洛韦片致血透患者严重精神神经异常1例及文献复习[J].中国中西医结合肾病杂志, 2017, 18(5): 442-443. [Duan XJ, Tan P, Zeng CQ. Severe psychoneurosis induced by varaciclovir tablets: a case report and literature review [J]. Chinese Journal of Integrated Traditional and Western Nephrology, 2017, 18 (5): 442-443.] DOI: 10.3969/j.issn.1009-587X.2017.05.024.

8.Thind GS, Roach R. A case of acyclovir neurotoxicity presenting with atypical cerebrospinal flu-id findings[J]. BMJ Case Rep, 2017, 2017: bcr2017220372. DOI: 10.1136/bcr-2017-220372.

9.Singh NP, Shah HR, Aggarwal N, et al. Valacyclovir associated neurotoxicity in a patient on dialysis[J]. Indian J Nephrol, 2014, 24(2): 128-129. DOI: 10.4103/0971-4065.127915.

10.Brandariz-Nuñez D, Correas-Sanahuja M, Maya-Gallego S, et al. Neurotoxicity associated with acyclo-vir and valacyclovir: a systematic review of cases[J]. J Clin Pharm Ther, 2021, 46(4): 918-926. DOI: 10.1111/jcpt.13464.

11.Okada T, Nakao T, Matsumoto H, et al. Valacyclovir neurotoxicity in a patient with end-stage renal disease treated with continuous ambulatory peritoneal dialysis[J]. Clin Nephrol, 2002, 58(2): 168-170. DOI: 10.5414/cnp58168.

12.Chowdhury MA, Derar N, Hasan S, et al. Acyclovir-induced neurotoxicity: a casereport and review of literature[J]. Am J Ther, 2016, 23(3): e941-e943. DOI: 10.1097/MJT.0000000000000093.

13.Kambhampati G, Pakkivenkata U, Kazory A. Valacy-clovir neurotoxicity can be effectively managed by hemodialysis[J]. Eur J Neurol, 2011, 18(3): e33. DOI: 10.1111/j.1468-1331.2010.03250.x.

14.郗玉玲, 平贯芳, 卢乙众. 注射用哌拉西林钠/舒巴坦钠不良反应影响因素 Logistic 回归分析[J]. 河南科技大学学报(医学版), 2019, 37(2): 142-145. [Xi YL, Ping GF, Lu YZ. Logistic regression analysis of influencing factors of adverse reactions of piperacil-lin sodium/sulbactam sodium for injection[J]. Journal of Henan University of Science & Technology (Medical Science), 2019, 37(2): 142-145. DOI: 10.15926/j.cnki.issn1672-688x.2019.02.019.

15.Thomas S, Kaweh P, Alina S, et al. Varicella zoster virus infections in neurological patients: a clinical study[J]. BMC Infect Dis, 2018, 18(1): 238. DOI: 10.1186/s12879-018-3137-2.

16.Rashiq S, Briewa L, Mooney M, et al. Distinguishing acyclovir neurotoxicity from encephalomyelitis[J]. J Intern Med, 1993, 234(5): 507-511. DOI: 10.1111/j.1365-2796.1993.tb00785.x.

17.Helldén A, Lycke J, Vander T, et al. The aciclovir metabolite CMMG is detectable in the CSF of subjects with neuropsychiatric symptoms during aciclovir and valaciclovir treatment[J]. J Antimicrob Chemother, 2006, 57(5): 945- 949. DOI: 10.1093/jac/dkl067.

18.Lindström J, Helldén A, Lycke J, et al. An unexpectedly high occurrence of aciclovir- induced neurop-sy-chiatric symptoms in patients treated for herpesvirus CNS infection: a prospective observational study[J]. J Antimicrob Chemother, 2019, 74(12): 3565-3572. DOI: 10.1093/jac/dkz357.

19.Gallacher PJ, Phelan PJ. Effective clearance of aciclovir using hemodiafiltration in a patient with neuro-toxicity[J]. Artif Organs, 2017, 41(5): 496-497. DOI: 10.1111/aor.12774.

20.Patel J, Hayes B, Bauler , et al. Neurologic acyclovir toxicity in the absence of kidney injury[J]. J Emerg Med, 2019, 57(2): e35-e39. DOI: 10.1016/j.jemermed.2019.03.050.