Striated nephrogram: probable acyclovir induced nephropathy

Case contributed by Ali Mashalla Åhre


Infection with suspicion of varicella. Treated with acyclovir. Develops right flank pain within a day. Rising serum creatinine prompts a CT of the abdomen to be obtained.

Patient Data

Age: 10 years
Gender: Female

Bilateral striated nephrogram sign.

Case Discussion

Acyclovir may cause acute renal failure/injury partly due to intratubular crystal precipitation (due to rapid excretion and low solubility), and partly due to direct tubular toxicity (acute tubular necrosis), which causes obstruction and inflammation. Symptoms usually occur within 24-48 hours with moderately (sometimes severely) rising serum-creatinine levels and abdominal pain. CT may show striated nephrogram sign due to contrast impaction in tubules as a result of tubular obstruction. Recovery usually occurs within 4-9 days after medication is discontinued. 

The patient's serum creatinine levels recovered four days after discontinuing the acyclovir treatment.

Volume repletion and slow drug infusion could prevent most cases of acyclovir-induced nephrotoxicity.

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