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OKAY BACK FROM THE PHARMACY 💊
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A WOMAN ON DIALYSIS DEVELOPED SHINGLES 🦠
A 2007 British Medical Journal Report Describes Two Cotard Cases
Its Authors Knew Of No Earlier Report Linking Cotard To A Drug
The First Patient Was A 35 Year Old Woman
Her Kidney Transplant Was Failing
She Was Being Treated With Chronic Dialysis
Then She Developed Shingles Which Doctors Call Herpes Zoster
Valaciclovir Was Prescribed At 1 Gram Daily
That Followed Swedish Recommendations For Renal Failure At The Time
She Took The First Dose After Dialysis On Day One
Two Nights Later She Became Restless
On Day Three She Was Tired And Her Body Felt Unfamiliar
By That Night Her Total Valaciclovir Dose Was 3 Grams
She Developed Anxiety And Visual And Auditory Hallucinations
The Next Morning She Came To The Dialysis Unit
She Could Barely Walk And Cried Out
Her Condition Improved After 45 Minutes Of Dialysis
After An Hour She Said She Had Been Convinced She Was Dead
Now She Was Not Quite So Sure
Valaciclovir Was Discontinued And She Was Admitted Overnight
The Next Day She Showed No Further Neuropsychiatric Symptoms
Doctors Found No Cause But Valaciclovir For Her Sense Of Being Dead
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A SECOND PATIENT AND THE DRUG 🧪
The Same Report Describes A 36 Year Old Man
He Had Received A Bone Marrow Transplant
Then He Developed Herpes Mucositis
He Was Treated With Oral Valaciclovir 500 Milligrams Twice A Day
On The Sixth Day He Was Admitted With Diarrhoea And Dehydration
His Plasma Creatinine Was 419 Micromoles Per Litre
One Month Earlier It Had Been 127
Herpes Encephalitis Was Suspected
Valaciclovir Was Replaced With Intravenous Aciclovir On Day Eight
On Day Nine He Was Screaming And Asking If He Was Dead
Intravenous Diazepam Eased His Symptoms Only Temporarily
Virus Tests On His Spinal Fluid Were Negative So Aciclovir Was Stopped
The Following Night The Feeling Of Being Dead Reappeared
He Again Believed He Was Dead During The Next Night
His Mental State And Renal Function Returned To Baseline On Day 12
Both Cases Involved Valaciclovir
Valaciclovir Is A Prodrug Of Aciclovir
Aciclovir Breaks Down In The Body Into A Compound Called CMMG
High Blood Levels Of It Were Linked To The Belief In Being Dead
Aciclovir And Valaciclovir May Cause Confusion And Hallucinations
Those Effects Occur Mainly In Patients With Poor Kidney Function
Both Patients Were Given Reduced Doses For Their Kidneys
Those Doses Were Recommended At That Time
The Authors Report Delusions Of Being Dead As An Adverse Drug Reaction
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WHAT DIALYSIS CHANGED 🩸
In The First Patient Dialysis Resulted In Rapid Improvement
Her Cotard Syndrome Subsided And A Hemineglect Syndrome Followed
Dialysis Lowered Her CMMG From 90.2 To 21.1 Micromoles Per Litre
The Authors Still Consider That Lower Value High
Their Earlier Work Linked Levels Above 10 To Neuropsychiatric Symptoms
The Second Patient Recovered Slowly Over Three Days
Their Summary States Patients With Kidney Impairment Seem At Risk
The Authors Say This Applies Even After Dose Reduction
Their Advice Covers Patients With This Drug Reaction And Renal Failure
They Say These Patients Should Preferably Go To The Dialysis Unit
That Is Instead Of The Department Of Psychiatry
A Separate Letter Published In 2018 Describes Another Cotard Case
The Patient Was A 55 Year Old Woman With Cancer In Both Kidneys
Dialysis Was Being Done At Her Home
Her Valaciclovir Dose Was Not Lowered To Match Her Kidney Function
The Letter Says It Should Have Been Cut To 500 Milligrams A Day
She Was Laughing And Dancing And Screaming That She Was In Heaven
Her Focus Throughout The First Assessment Was On Being Dead
Dialysis Sessions Lasted 4 Hours On 3 Consecutive Days
By Day 2 Her Nihilistic Delusions Had Disappeared
Her Return To Baseline Was Complete On Day 3
The Letter States A 4 Hour Session Reduces CMMG By 64 Percent
Its Authors Expect Signs Of Toxicity To Subside With Daily Dialysis
