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Lim APW, Sung J, Ramburuth V, Oyibo SO. Acyclovir-Induced Nephrotoxicity and Neurotoxicity: A Report of Two Cases. Cureus 2024; 16:e52367. [PMID: 38234392 PMCID: PMC10792401 DOI: 10.7759/cureus.52367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 01/19/2024] Open
Abstract
Acyclovir is a widely used antiviral agent used to treat viral meningitis. Although well tolerated, on rare occasions, it can cause severe nephrotoxicity and neurotoxicity. It is recommended that the dose of intravenous acyclovir be calculated based on the ideal body weight for height rather than the actual weight in obese patients to avoid excessive dosage. We report two patients who developed severe acute kidney injury and neurological symptoms while on intravenous acyclovir therapy. The first patient was a 57-year-old obese woman known to have epilepsy who received a dose of intravenous acyclovir based on her actual weight of 80 kg and subsequently developed acyclovir-induced nephrotoxicity and increased seizure activity. The second patient was a 60-year-old, slightly overweight, man, who received a dose of intravenous acyclovir based on his actual weight of 80 kg and subsequently developed both acyclovir-induced nephrotoxicity and possible neurotoxicity. No other cause for the deterioration in renal function or neurological symptoms was identified, and there was rapid recovery within three days of stopping acyclovir therapy. This case report emphasizes the importance of monitoring renal function while patients are on intravenous acyclovir therapy and highlights the fact that even non-obese, overweight patients are at risk of toxicity when their actual body weight instead of their ideal body weight for height is used for intravenous acyclovir dose calculation.
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Affiliation(s)
| | - Jaeeun Sung
- General Medicine, Peterborough City Hospital, Peterborough, GBR
| | - Vivek Ramburuth
- Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, GBR
| | - Samson O Oyibo
- Diabetes and Endocrinology, Peterborough City Hospital, Peterborough, GBR
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2
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Oh PS, Han YH, Lim S, Jeong HJ. Blue light irradiation exerts anti-viral and anti-inflammatory properties against herpes simplex virus type 1 infection. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY. B, BIOLOGY 2023; 239:112632. [PMID: 36608399 PMCID: PMC9771843 DOI: 10.1016/j.jphotobiol.2022.112632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
The aim of this study was to investigate the antiviral and anti-inflammatory functions of blue light (BL) in cutaneous viral infections. Previously, we examined the photo-biogoverning role of 450 nm BL in SARS-CoV-2-infected cells, which showed that photo-energy could inhibit viral activation depending on the number of photons. However, the communication network between photo-energy irradiation and immune cells involved in viral infections has not been clarified. We verified viral activation, inflammatory responses, and relevant downstream cascades caused by human simplex virus type I (HSV-1) after BL irradiation. To examine the antiviral effect of BL, we further tested whether BL could disturb viral absorption or entry into host cells. The results showed that BL irradiation, but not green light (GL) exposure, specifically decreased plaque-forming activity and viral copy numbers in HSV-1-infected cells. Accumulated BL irradiation inhibited the localization of viral proteins and the RNA expression of characteristic viral genes such as UL19, UL27, and US6, thus exerting to an anti-viral effect. The results also showed that BL exposure during viral absorption interfered with viral entry or destroyed the virus, as assessed by plaque formation and quantitative PCR assays. The levels of the pro-inflammatory mediators interleukin (IL)-18 and IL-1β in M1-polarized macrophages were increased by HSV-1 infection. However, these increases were attenuated by BL irradiation. Importantly, BL irradiation decreased cGAS and STING expression, as well as downstream NF-κB p65, in M1-polarized HSV-1-infected macrophages, demonstrating anti-viral and anti-inflammatory properties. These findings suggest that BL could serve as an anti-viral and anti-inflammatory therapeutic candidate to treat HSV-1 infections.
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Affiliation(s)
- Phil-Sun Oh
- Department of Nuclear Medicine, Molecular Imaging & Therapeutic Medicine Research Center, Research Institute of Clinical Medicine of Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Medical School and Hospital, Jeonju 54907, Republic of Korea
| | - Yeon-Hee Han
- Department of Nuclear Medicine, Molecular Imaging & Therapeutic Medicine Research Center, Research Institute of Clinical Medicine of Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Medical School and Hospital, Jeonju 54907, Republic of Korea
| | - SeokTae Lim
- Department of Nuclear Medicine, Molecular Imaging & Therapeutic Medicine Research Center, Research Institute of Clinical Medicine of Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Medical School and Hospital, Jeonju 54907, Republic of Korea
| | - Hwan-Jeong Jeong
- Department of Nuclear Medicine, Molecular Imaging & Therapeutic Medicine Research Center, Research Institute of Clinical Medicine of Jeonbuk National University, Biomedical Research Institute of Jeonbuk National University Medical School and Hospital, Jeonju 54907, Republic of Korea.
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3
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Petrillo F, Petrillo A, Sasso FP, Schettino A, Maione A, Galdiero M. Viral Infection and Antiviral Treatments in Ocular Pathologies. Microorganisms 2022; 10:2224. [PMID: 36363815 PMCID: PMC9694090 DOI: 10.3390/microorganisms10112224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 08/27/2023] Open
Abstract
Ocular viral infections are common and widespread globally. These infectious diseases are a major cause of acute red eyes and vision loss. The eye and its nearby tissues can be infected by several viral agents, causing infections with a short course and limited ocular implications or a long clinical progression and serious consequences for the function and structure of the ocular region. Several surveillance studies underline the increased emergence of drug resistance among pathogenic viral strains, limiting treatment options for these infections. Currently, in the event of resistant infections, topical or systemic corticosteroids are useful in the management of associated immune reactions in the eye, which contribute to ocular dysfunction. Many cases of viral eye infections are misdiagnosed as being of bacterial origin. In these cases, therapy begins late and is not targeted at the actual cause of the infection, often leading to severe ocular compromises, such as corneal infiltrates, conjunctival scarring, and reduced visual acuity. The present study aims at a better understanding of the viral pathogens that cause eye infections, along with the treatment options available.
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Affiliation(s)
- Francesco Petrillo
- Azienda Ospedaliera Universitaria-Città della Salute e della Scienza di Torino, 10126 Torino, Italy
| | | | | | - Antonietta Schettino
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
| | - Angela Maione
- Department of Biology, University of Naples Federico II, 80126 Naples, Italy
| | - Marilena Galdiero
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy
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4
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IN SILICO INVESTIGATION OF ACYCLOVIR DERIVATIVES POTENCY AGAINST HERPES SIMPLEX VIRUS. SCIENTIFIC AFRICAN 2022. [DOI: 10.1016/j.sciaf.2022.e01461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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5
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Shahbazi F, Shojaei L, Farvadi F, Kadivarian S. Antimicrobial safety considerations in critically ill patients: part II: focused on anti-microbial toxicities. Expert Rev Clin Pharmacol 2022; 15:563-573. [PMID: 35734938 DOI: 10.1080/17512433.2022.2093716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics. AREAS COVERED In the current article we searched PubMed, Scopus and Google Scholar for neurotoxicities, hematologic toxicity and fluid stewardship in intensive care units. EXPERT OPINION Critically ill patients who receive antimicrobial agents should be monitored for neurological, hematologic toxicities especially seizure, thrombocytopenia, and clostridioides infections. Other toxicities including QTc prolongation, electrolyte disturbances, liver enzyme elevation, and infusion-related reactions were being considered. Other changes, including fluid overload, hypoalbuminemia, augmented renal clearance, increased cardiac outputs in septic shock, and acute kidney injury, may influence treatment efficiency and patient outcome.
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Affiliation(s)
- Foroud Shahbazi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Lida Shojaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fakhrossadat Farvadi
- Center for nanotechnology in drug delivery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Kadivarian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Liu Y, Chen L, Liu W, Li D, Zeng J, Tang Q, Zhang Y, Luan F, Zeng N. Cepharanthine Suppresses Herpes Simplex Virus Type 1 Replication Through the Downregulation of the PI3K/Akt and p38 MAPK Signaling Pathways. Front Microbiol 2021; 12:795756. [PMID: 34956164 PMCID: PMC8696181 DOI: 10.3389/fmicb.2021.795756] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/08/2021] [Indexed: 12/23/2022] Open
Abstract
Cepharanthine (CEP) is a naturally occurring isoquinoline alkaloid extracted from Stephania cepharantha Hayata. Although its underlying molecular mechanism is not fully understood, this compound is reported as a promising antiviral drug. In the present study, we explore the anti-HSV-1 effects and the underlying molecular mechanisms of CEP in vitro. Our results show that CEP could significantly inhibit the formation of plaque and the expression of viral proteins and exhibit a general suppression of replication-associated genes. Whereas HSV-1 infection increases the expressions of phosphoinositide 3-kinase (PI3K), protein kinase B (Akt), and p38 mitogen-activated protein kinase (p38 MAPK) in host cells, CEP was effective indirectly inhibiting phosphorylation levels of the targets in PI3K/Akt and p38 MAPK signaling pathways. Moreover, CEP markedly decreased G0/G1 phase and increased G2/M phase cells and decreased the expression of cyclin-dependent kinase1 (CDK1) and cyclinB1 in a dose-dependent manner. Additionally, CEP increased apoptosis in infected cells, reduced B cell lymphoma-2 (Bcl-2) protein levels, and increased the protein levels of Bcl-associated X protein (Bax), cleaved-caspase3, and nuclear IκB kinaseα (IκBα). Collectively, CEP could arrest the cell cycle in the G2/M phase and induce apoptosis in infected cells by inhibiting the PI3K/Akt and p38 MAPK signaling pathways, hence further reducing HSV-1 infection and subsequent reproduction.
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Affiliation(s)
- Yao Liu
- State Key Laboratory of South Western Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.,School of Laboratory Medicine, Chengdu Medical College, Chengdu, China
| | - Li Chen
- State Key Laboratory of South Western Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.,Department of Pharmacy, Clinical Medical College and the First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Wenjun Liu
- School of Bioscience and Technology, Chengdu Medical College, Chengdu, China
| | - Dan Li
- School of Bioscience and Technology, Chengdu Medical College, Chengdu, China
| | - Jiuseng Zeng
- State Key Laboratory of South Western Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qiong Tang
- State Key Laboratory of South Western Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yuexin Zhang
- School of Bioscience and Technology, Chengdu Medical College, Chengdu, China
| | - Fei Luan
- State Key Laboratory of South Western Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Nan Zeng
- State Key Laboratory of South Western Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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Liu Y, Tang Q, Rao Z, Fang Y, Jiang X, Liu W, Luan F, Zeng N. Inhibition of herpes simplex virus 1 by cepharanthine via promoting cellular autophagy through up-regulation of STING/TBK1/P62 pathway. Antiviral Res 2021; 193:105143. [PMID: 34303748 DOI: 10.1016/j.antiviral.2021.105143] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/14/2021] [Accepted: 07/21/2021] [Indexed: 02/08/2023]
Abstract
Cepharanthine (CEP), a naturally occurring isoquinoline alkaloid extracted from the genus CEP of the Tetrandrine family, was reported to possess many biological activities such as anti-inflammatory, antitumor, antiviral, and immune-enhancing effects. Nevertheless, the underlying mechanisms of CEP against herpes simplex virus type 1 (HSV-1) are still elusive. In this study, we explored the anti-HSV effects and mechanisms of CEP in vitro. The results showed that CEP possessed a strong inhibitory effect against HSV-1 infection with the TC50 of 5.4 μg/mL, the IC50 of 0.835 μg/mL, and the TI of 6.47. Most importantly, CEP could promote the phosphorylation of STING, TBK1, and P62 and the expression of LC3II without induction of interferon by directly targeting the STING/TBK1/P62 signaling pathways. Electron microscopy showed that autophagy induced by CEP could degrade viral particles and cellular components. RT-PCR results revealed that a sharp reduction of large numbers of virus gene transcription in 16 h after CEP treatment. Furthermore, CEP also reduced the HSV-1 gB and gC transcription. In conclusion, one of the effects of CEP was to promote interferon-independent autophagy through STING mediated signaling.
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Affiliation(s)
- Yao Liu
- State Key Laboratory of South Western Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, PR China; School of Laboratory Medicine, Chengdu Medical College, Chengdu, Sichuan 610083, PR China
| | - Qiong Tang
- State Key Laboratory of South Western Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, PR China
| | - Zhili Rao
- State Key Laboratory of South Western Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, PR China
| | - Yang Fang
- State Key Laboratory of South Western Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, PR China
| | - Xinni Jiang
- School of Bioscience and Technology, Chengdu Medical College, Chengdu, Sichuan 610083, PR China
| | - Wenjun Liu
- School of Bioscience and Technology, Chengdu Medical College, Chengdu, Sichuan 610083, PR China
| | - Fei Luan
- State Key Laboratory of South Western Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, PR China.
| | - Nan Zeng
- State Key Laboratory of South Western Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan 611137, PR China.
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8
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Brandariz-Nuñez D, Correas-Sanahuja M, Maya-Gallego S, Martín Herranz I. Neurotoxicity associated with acyclovir and valacyclovir: A systematic review of cases. J Clin Pharm Ther 2021; 46:918-926. [PMID: 34146428 DOI: 10.1111/jcpt.13464] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/15/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Acyclovir and valacyclovir are commonly used antivirals with good general tolerance. Despite their good safety profile, they can cause systemic adverse effects, such as neurotoxicity, which are less frequent and known. The objective of this review was to collect all the reported cases of neurotoxicity associated with acyclovir and valaciclovir published in the literature and characterize their clinical course and interventions. METHODS A systematic review of cases was carried out following the guidelines established by "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA). The research was carried out using the PubMed-Medline and Embase databases, between July 1984 and March 2021. RESULTS AND DISCUSSION A total of 119 cases with neurotoxicity mainly related to acyclovir (n = 88; 73.9%), followed by valaciclovir (n = 35; 29.4%) were analysed. 49.6% (n = 59) were men with a mean age of 59.5 years ± 21.1 (0.5-88). In 83.3% of the cases, renal impairment was documented and 57.1% (n = 68) with end-stage renal disease. The administered dose was higher than the renal adjustment recommendations in 59.7% of the cases. The global mean of onset of symptoms was 3.1 days ± 4.3 (0.2-28) after the start of antivirals. The mean recovery time was 9.8 days ± 21.7 (0.2-180). 74.4% of the patients had a recovery of ≤7 days, 15.9% between 8 and 15 days and 9.8% > 15 days. WHAT IS NEW AND CONCLUSION The neurotoxicity induced by acyclovir and its derivative valacyclovir is a poorly known and rare adverse effect that can occur mainly in patients with advanced age and impaired renal function. The most characteristic symptoms are confusion, altered level of consciousness, hallucinations, agitation and dysarthria. The basis of treatment is the discontinuation of the antiviral, and in some cases, it may require additional clearance by dialysis.
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Affiliation(s)
| | | | - Sara Maya-Gallego
- Pediatric Infectious Disease Service, San Joan de Deu Hospital, Barcelona, Spain
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9
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Obisesan O, Katata-Seru L, Mufamadi S, Mufhandu H. Applications of Nanoparticles for Herpes Simplex Virus (HSV) and Human Immunodeficiency Virus (HIV) Treatment. J Biomed Nanotechnol 2021; 17:793-808. [PMID: 34082867 DOI: 10.1166/jbn.2021.3074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In recent years, the growing studies focused on the immunotherapy of hepatocellular carcinoma and proved the preclinical and clinical promises of host antitumor immune response. However, there were still various obstacles in meeting satisfactory clinic need, such as low response rate, primary resistance and secondary resistance to immunotherapy. Tackling these barriers required a deeper understanding of immune underpinnings and a broader understanding of advanced technology. This review described immune microenvironment of liver and HCC which naturally decided the complexity of immunotherapy, and summarized recent immunotherapy focusing on different points. The ever-growing clues indicated that the instant killing of tumor cell and the subsequent relive of immunosuppressive microenvironment were both indis- pensables. The nanotechnology applied in immunotherapy and the combination with intervention technology was also discussed.
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Affiliation(s)
- Oluwafemi Obisesan
- Department of Interventional Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, 110000, China
| | - Lebogang Katata-Seru
- Department of Interventional Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, 110000, China
| | - Steven Mufamadi
- Department of Interventional Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, 110000, China
| | - Hazel Mufhandu
- Department of Interventional Radiology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, 110000, China
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10
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Kenzaka T, Sugimoto K, Goda K, Akita H. Acute kidney injury and acyclovir-associated encephalopathy after administration of valacyclovir in an elderly person with normal renal function: A case report and literature review. Medicine (Baltimore) 2021; 100:e26147. [PMID: 34032768 PMCID: PMC8154488 DOI: 10.1097/md.0000000000026147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/11/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Acyclovir (ACV)-associated encephalopathy is related to an increase in plasma levels of 9-carboxymethoxymethylguanine, an ACV metabolite, and is often reported in patients with renal dysfunction. We report a case of ACV-associated encephalopathy with rapid progression of renal dysfunction after oral administration of valacyclovir (VACV) and review literature of previous ACV-associated encephalopathy cases. PATIENT CONCERNS An 88-year-old man was diagnosed with herpes zoster. VACV (3000 mg/day) treatment was initiated. Serum creatinine (Cr) level was 0.80 mg/dL. However, irritability, memory impairment, and decreased responsiveness occurred after 3 days. The Cr level was 6.76 mg/dL on admission. DIAGNOSIS He was diagnosed with ACV-associated encephalopathy with acute kidney injury. INTERVENTIONS VACV was discontinued, hemodialysis was initiated on the day of admission, and then the signs and symptoms improved approximately 72 hours after the admission. CONCLUSION Worsening of renal function and encephalopathy should be a focus when using VACV or ACV, regardless of age and original renal function. Acute kidney injury and ACV-associated encephalopathy may particularly occur in the elderly even when renal function is normal. Therefore, regular monitoring of renal function and consciousness is necessary during VACV treatment.
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Affiliation(s)
- Tsuneaki Kenzaka
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba
- Division of Community Medicine and Career Development, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazuma Sugimoto
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba
| | - Ken Goda
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba
- Division of Community Medicine and Career Development, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hozuka Akita
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba
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11
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Downes KJ, Goldman JL. Too Much of a Good Thing: Defining Antimicrobial Therapeutic Targets to Minimize Toxicity. Clin Pharmacol Ther 2021; 109:905-917. [PMID: 33539569 DOI: 10.1002/cpt.2190] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/27/2021] [Indexed: 12/19/2022]
Abstract
Antimicrobials are a common cause of drug toxicity. Understanding the relationship between systemic antimicrobial exposure and toxicity is necessary to enable providers to take a proactive approach to prevent undesired drug effects. When an exposure threshold has been defined that predicts drug toxicity, therapeutic drug monitoring (TDM) can be performed to assure drug exposure does not exceed the defined threshold. Although some antimicrobials have well-defined dose-dependent toxicities, many other exposure-toxicity relationships have either not been well-defined or, in some cases, not been evaluated at all. In this review, we examine the relationship between exposures and toxicities for antibiotic, antifungal, and antiviral agents. Furthermore, we classify these relationships into four categories: known association between drug exposure and toxicity such that clinical implementation of a specific exposure threshold associated with toxicity for TDM is supported (category 1), known association between drug exposure and toxicity but the specific exposure threshold associated with toxicity is undefined (category 2), association between drug exposure and toxicity has been suggested but relationship is poorly defined (category 3), and no known association between drug exposure and toxicity (category 4). Further work to define exposure-toxicity thresholds and integrate effective TDM strategies has the potential to minimize many of the observed antimicrobial toxicities.
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Affiliation(s)
- Kevin J Downes
- The Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,The Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer L Goldman
- Divisions of Clinical Pharmacology, Toxicology and Therapeutic Innovation and Infectious Diseases, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Pediatrics, University of Missouri - Kansas City, Kansas City, Missouri, USA
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12
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Viceconti M, Pappalardo F, Rodriguez B, Horner M, Bischoff J, Musuamba Tshinanu F. In silico trials: Verification, validation and uncertainty quantification of predictive models used in the regulatory evaluation of biomedical products. Methods 2020; 185:120-127. [PMID: 31991193 PMCID: PMC7883933 DOI: 10.1016/j.ymeth.2020.01.011] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/10/2019] [Accepted: 01/14/2020] [Indexed: 02/03/2023] Open
Abstract
Regulators now consider also evidences produced in silico. We need accepted methods to evaluate the credibility of models. In this paper we describe the use of the ASME V&V-40 technical standard. We also discuss its application to various types of modelling methods.
Historically, the evidences of safety and efficacy that companies provide to regulatory agencies as support to the request for marketing authorization of a new medical product have been produced experimentally, either in vitro or in vivo. More recently, regulatory agencies started receiving and accepting evidences obtained in silico, i.e. through modelling and simulation. However, before any method (experimental or computational) can be acceptable for regulatory submission, the method itself must be considered “qualified” by the regulatory agency. This involves the assessment of the overall “credibility” that such a method has in providing specific evidence for a given regulatory procedure. In this paper, we describe a methodological framework for the credibility assessment of computational models built using mechanistic knowledge of physical and chemical phenomena, in addition to available biological and physiological knowledge; these are sometimes referred to as “biophysical” models. Using guiding examples, we explore the definition of the context of use, the risk analysis for the definition of the acceptability thresholds, and the various steps of a comprehensive verification, validation and uncertainty quantification process, to conclude with considerations on the credibility of a prediction for a specific context of use. While this paper does not provide a guideline for the formal qualification process, which only the regulatory agencies can provide, we expect it to help researchers to better appreciate the extent of scrutiny required, which should be considered early on in the development/use of any (new) in silico evidence.
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Affiliation(s)
- Marco Viceconti
- Department of Industrial Engineering, Alma Mater Studiorum - University of Bologna, Italy; Medical Technology Lab, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
| | | | - Blanca Rodriguez
- Department of Computer Science, British Heart Foundation Centre of Research Excellence, University of Oxford, UK
| | | | - Jeff Bischoff
- Corporate Research Department, Zimmer Biomet, Warsaw, IN, USA
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Abstract
Antimicrobials are a widely used class of medications, but several of them are associated with neurological and psychiatric side effects. The exact incidence of neurotoxicity with anti-infectives is unknown, although it is estimated to be < 1%. Neurotoxicity occurs with all classes of antimicrobials, such as antibiotics, antimycobacterials, antivirals, antifungals and antiretrovirals, with side effects ranging from headaches, anxiety and depression to confusion, delirium, psychosis, mania and seizures, among others. It is important to consider these possible side effects to prevent misdiagnosis or delayed treatment as drug withdrawal can be associated with reversibility in most cases. This article highlights the different neurotoxic effects of a range of antimicrobials, discusses proposed mechanisms of onset and offers general management recommendations. The effects of antibiotics on the gut microbiome and how they may ultimately affect cognition is also briefly examined.
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Affiliation(s)
- Madison K Bangert
- Section of Infectious Diseases, Department of Medicine, UT Health McGovern Medical School, 6431 Fannin St. MSB 2.112, Houston, TX, 77030, USA
| | - Rodrigo Hasbun
- Section of Infectious Diseases, Department of Medicine, UT Health McGovern Medical School, 6431 Fannin St. MSB 2.112, Houston, TX, 77030, USA.
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14
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Drug Reaction with Eosinophilia and Systemic Symptoms (DReSS): How Far Have We Come? Am J Clin Dermatol 2019; 20:217-236. [PMID: 30652265 DOI: 10.1007/s40257-018-00416-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Drug reaction with eosinophilia and systemic symptoms (DReSS), also known as drug-induced hypersensitivity syndrome (DiHS), is an uncommon severe adverse reaction to medications. It is important to recognize it as it is potentially fatal and can cause significant morbidity. From the first reports of drug reactions related to certain anticonvulsants characterized by fever, liver enzyme elevation, and skin changes, our continuously growing understanding of this entity has allowed us to describe its physiopathology and clinical features even further. The relationship of genetic factors, viral activation, and specific drug exposure is now known to play a role in this disease. There is still not a widely accepted marker for DReSS/DiHS, but the spectrum of clinical and laboratory features has now been better outlined. The mainstay of treatment is the use of systemic corticosteroids, but other options such as intravenous immunoglobulin, cyclosporine, mycophenolate mofetil, rituximab, and cyclophosphamide have been described. We present a comprehensive review of the literature on DReSS/DiHS, focusing on its history, etiopathogenesis, diagnosis, therapeutic approach, and outcome.
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