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Acute kidney injury secondary to intratubular precipitation of crystals
35%
68/192
Cross-reactivity with penicillin
20%
38/192
Diffuse flushing upon infusion secondary to pseudoallergic drug reaction
24%
47/192
Prophylaxis against group B streptococcus in pregnant patients
6%
11/192
Plasminogen cleavage into plasmin via protease activity
9%
18/192
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The patient's clinical presentation, MRI, and CSF findings are consistent with herpes simplex virus (HSV) encephalitis. HSV encephalitis is immediately treated with intravenous (IV) acyclovir, which can cause a drug-induced crystal nephropathy. HSV encephalitis is commonly caused by HSV-1, but can also occur with HSV-2. Patients can present with fever, headache, altered mental status, seizures, and focal neurological deficits. HSV encephalitis commonly affects the temporal lobes, and mortality is high in patients who are untreated. Prompt treatment with IV acyclovir will improve morbidity and mortality. Acyclovir is associated with a drug-induced crystalline nephropathy, thus making adequate hydration essential in decreasing this risk. Figure A is a coronal T2-weighted MRI showing hyperintensity in the temporal lobes. In the setting of CSF findings suggestive of a viral process with temporal involvement on MRI, HSV encephalitis high on the differential. Incorrect Answers: Answer 2: Cross-reactivity with penicillin is suggestive of cephalosporins. Although ceftriaxone is used to treat meningitis, this patient's findings are more suggestive of an encephalitis of viral etiology. Answer 3: Diffuse flushing upon infusion secondary to pseudoallergic drug reaction describes "red-man syndrome." This drug hypersensitivity is associated with vancomycin. CSF findings are not suggestive of bacterial meningitis. Answer 4: Penicillin G or ampicillin can be used as prophylaxis for pregnant patients carrying group B streptococcus. It's important to note that ampicillin can be used to treat bacterial meningitis caused by Listeria monocytogenes. This would be part of meningitis treatment in the immunocompromised, elderly, and neonates. Answer 5: Plasminogen cleavage into plasmin via protease activity describes tissue plasminogen activator (tPA). This medication is used in the treatment of ischemic stroke. The patient presents with a viral encephalitis, not a stroke. Bullet Summary: Acyclovir can cause a drug-induced crystal nephropathy.
4.8
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