Acyclovir Extravasation: Case Report and Review of the Literature

Case Report

Austin J Orthopade & Rheumatol. 2016; 3(1): 1026.

Acyclovir Extravasation: Case Report and Review of the Literature

Lau BC* and Lee NH

Department of Orthopaedic Surgery, University of California San Francisco Medical Center, USA

*Corresponding author: Lau BC, Department of Orthopaedic Surgery, University of California San Francisco Medical Center, 400 Parnassus Avenue, San Francisco, CA 94143, USA

Received: April 06, 2016; Accepted: May 02, 2016; Published: May 05, 2016


Background: Infiltration and extravasation of solutions is a common, under-reported problem with potentially severe morbidity. We report a case of intravenous extravasation of acyclovir and discuss our approach and management of this incident.

Methods: We describe a case of acyclovir extravasation and provide a literature review on the general management of extravasation injuries. PubMed articles in the English Language were used for this review. Informed consent was obtained from all individual participants included in the study.

Results: Close observation and extremity elevation with cold compresses was an adequate treatment for our patient. At final follow-up, the patient had some residual soft tissue swelling but no functional deficits.

Conclusion: Knowledge of general management principles and tailoring treatment based on properties of the solution, amount of solution extravasated, and the overall clinical picture will optimize outcomes of this common and potential sentinel event.

Keywords: Extravasation of intravenous; Herpes simplex virus; Human immunodeficiency virus


An inadvertent extravasation of intravenous (IV medication occurs in 0.1% to 6/5% of hospital patients, but the actual incidence is likely higher due to inconsistent documentation and reporting [1]. At first these injuries may appear innocuous, but there is a risk of severe and progressive tissue dysfunction ranging from persistent tissue edema and fibrosis to delayed tissue necrosis [1]. These changes can be irreversible. A devastating potential sequela of an unmanaged intravenous infiltration or extravasation is the development of compartment syndrome and its subsequent morbidity. Rapid cessation of the offending agent and prompt management based on the identification of the infused solution is critical to prevent further morbidity.

Acyclovir is a highly potent inhibitor of Herpes Simplex Virus (HSV), type 1 and 2, and varicella zoster virus [2]. Its use has increased due to a greater number of immunocompromised patients, particularly Human Immunodeficiency Virus (HIV) and oncology patients treated with chemotherapy, that require prophylactic or treatment doses for HSV-related diseases [3]. The management of acyclovir extravasation is not clearly defined in the literature.

We present a case report of an IV extravasation of acyclovir and review the literature on management of IV extravasations.

Case Report

A 55-year-old African male police officer with HIV visiting from Kenya presented to the hospital with 2 weeks of acute worsening of baseline action tremors of bilateral upper extremities and an ataxic gait. He also endorsed 2 weeks of diplopia and photophobia. He was only alert and oriented to self on initial presentation. The patient was admitted to the neurology service for further evaluation with concern for underlying ischemia, infection, or an inflammatory process. The patient was started empirically on 700mg IV q8 hour acyclovir through an IV catheter placed on the dorsum of his right hand for possible herpes simplex encephalitis.

The orthopaedic hand service was consulted approximately 2 hours following extravasation of 150mL of IV acyclovir into the dorsum of the right hand on hospital day 2. Examination of the right hand demonstrated diffuse swelling that was firm but compressible. No apparent skin breakdown or necrosis was noted (Figure 1A & 1B).The patient denied pain with passive stretch of his digits. The patient was unable to fully flex his fingers secondary to the swelling but was able to be passively flexed to a complete grip. His two-point discrimination was 3mm in all digits and the thumb and capillary refill was less than 2 seconds in all digits with a 2+ radial pulse. The right upper extremity was placed in a skyhook (hand placed in a stockinette which was tied to an IV pole to keep the upper extremity elevated) and his hand compartments were evaluated every 2 hours for the first 24 hours. The hand was wrapped in webril and cold compresses applied 4 times a day for 15 minute intervals. The patient was consented for possible emergent surgery in case his symptoms acutely worsened.