Presumed Group B Streptococcal Meningitis After Epidural Blood Patch Yaakov Beilin, MD, and Yelena Spitzer, MD Bacterial meningitis after epidural catheter placement is rare. We describe a case in which a parturient received labor epidural analgesia for vaginal delivery complicated by dural puncture. The patient developed postdural puncture headache and underwent 2 separate epidural blood patch procedures. She subsequently developed a headache with fever and focal neurologic deficits. She was treated with broad spectrum antibiotics for presumed meningitis, and she made a full recovery. Blood cultures subsequently grew group B streptococcus. (A&A Case Reports. 2015;4:163–5.)
D
ural puncture with a resultant postdural puncture headache is a known complication of epidural catheter placement. Epidural blood patch (EBP) is commonly performed to treat postdural puncture headache and is generally safe. We report a case of suspected group B streptococcal (GBS) meningitis after unintentional dural puncture during epidural catheter placement followed by 2 EBP procedures. The patient gave written consent to publish the circumstances surrounding her delivery.
CASE DESCRIPTION
A 30-year-old female, gravida 1 para 0, presented to the labor and delivery suite at 38 weeks’ gestation in active labor. Her medical history was significant for thyroidectomy and a positive recto-vaginal GBS screen performed at 36 weeks. Chemoprophylaxis for GBS, as per routine, consisting of 2 g of IV ampicillin, was started on admission followed by 2 g 4 hours later. The patient requested labor epidural analgesia 2 hours after admission, which was 2 hours after the first dose of ampicillin. An epidural catheter was placed with the patient in the sitting position, under sterile conditions, with loss of resistance to air at the L3-L4 interspace, with a 17-gauge Tuohy needle. Sterile technique included hand washing with an alcohol-based solution and donning of sterile gloves, hat, and mask by the anesthesiologist, and sterile preparation and drape of the back with DuraPrep® (combination of iodine povacrylex and isopropyl alcohol). On the first attempt at epidural catheter placement dural puncture occurred, and the procedure was successfully repeated at the L2-L3 interspace. The patient remained afebrile and hemodynamically stable during labor and delivery.
From the Department of Anesthesiology, Icahn School of Medicine, New York, New York. Yelena Spitzer, MD, is currently affiliated with Department of Anesthesiology, Albert Einstein College of Medicine of Yeshiva University, Bronx, New York. Accepted for publication December 2, 2014. Funding: Departmental funding. The authors declare no conflicts of interest. This report was previously presented, in part, at the Society of Obstetric Anesthesiology and Perinatology. Address correspondence to Yaakov Beilin, MD, Department of Anesthesiology, Icahn School of Medicine, 1 Gustave L. Levy Place, Box 1010, New York, NY 10029. Address e-mail to [email protected]. Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000155
The patient delivered a healthy baby boy 5 hours after admission. She required a mediolateral episiotomy for delivery and sustained a left periurethral laceration; both of which were repaired uneventfully. Soon after delivery, the patient complained of a postural headache. The patient remained afebrile with stable vital signs. An EBP was performed in a sterile fashion, as described above, on postpartum day (PPD) 1 at the L2-L3 interspace with 20 mL autologous blood drawn in a sterile manner from a vein in the patient’s arm. The patient had full resolution of symptoms and was discharged to home on PPD2. Her headache recurred and was once again positional, and the patient returned on PPD4 for repeat EBP. The patient was afebrile, and her white blood cell count before the EBP was 8500 cells/μL with a normal differential consisting of 71% neutrophils, 23% lymphocytes, and 0.3% basophils. The procedure was repeated at the L3-L4 interspace in a sterile fashion, as described above, and the patient reported symptomatic improvement and was discharged to home later that day. On PPD5, the patient returned alert and oriented × 3, febrile to 38.6°C orally with a severe unrelenting nonpostural headache associated with nausea. Thirty minutes after arrival, the patient developed focal neurologic deficits, manifesting as expressive and receptive aphasia, as well as disorientation. A neurology and infectious disease consult was requested. Physical examination revealed nuchal rigidity with reflexive flexion of the legs. Examination of the back was unremarkable without any evidence of infection. Emergent computerized tomographic scan of the head was unremarkable without signs of infarct or hemorrhage. Laboratory results were significant for a white blood cell count of 18,900 cells/μL and 24% bands. Blood, urine, and cerebral spinal fluid (CSF) cultures were performed. The patient was empirically started on IV vancomycin, cefepime, ampicillin, acyclovir, and dexamethasone for suspected meningitis. Lumbar puncture results revealed a white blood cell count of 7790 cells/μL, protein 525 mg/dL, and glucose
D
ural puncture with a resultant postdural puncture headache is a known complication of epidural catheter placement. Epidural blood patch (EBP) is commonly performed to treat postdural puncture headache and is generally safe. We report a case of suspected group B streptococcal (GBS) meningitis after unintentional dural puncture during epidural catheter placement followed by 2 EBP procedures. The patient gave written consent to publish the circumstances surrounding her delivery.
CASE DESCRIPTION
A 30-year-old female, gravida 1 para 0, presented to the labor and delivery suite at 38 weeks’ gestation in active labor. Her medical history was significant for thyroidectomy and a positive recto-vaginal GBS screen performed at 36 weeks. Chemoprophylaxis for GBS, as per routine, consisting of 2 g of IV ampicillin, was started on admission followed by 2 g 4 hours later. The patient requested labor epidural analgesia 2 hours after admission, which was 2 hours after the first dose of ampicillin. An epidural catheter was placed with the patient in the sitting position, under sterile conditions, with loss of resistance to air at the L3-L4 interspace, with a 17-gauge Tuohy needle. Sterile technique included hand washing with an alcohol-based solution and donning of sterile gloves, hat, and mask by the anesthesiologist, and sterile preparation and drape of the back with DuraPrep® (combination of iodine povacrylex and isopropyl alcohol). On the first attempt at epidural catheter placement dural puncture occurred, and the procedure was successfully repeated at the L2-L3 interspace. The patient remained afebrile and hemodynamically stable during labor and delivery.
From the Department of Anesthesiology, Icahn School of Medicine, New York, New York. Yelena Spitzer, MD, is currently affiliated with Department of Anesthesiology, Albert Einstein College of Medicine of Yeshiva University, Bronx, New York. Accepted for publication December 2, 2014. Funding: Departmental funding. The authors declare no conflicts of interest. This report was previously presented, in part, at the Society of Obstetric Anesthesiology and Perinatology. Address correspondence to Yaakov Beilin, MD, Department of Anesthesiology, Icahn School of Medicine, 1 Gustave L. Levy Place, Box 1010, New York, NY 10029. Address e-mail to [email protected]. Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000155
The patient delivered a healthy baby boy 5 hours after admission. She required a mediolateral episiotomy for delivery and sustained a left periurethral laceration; both of which were repaired uneventfully. Soon after delivery, the patient complained of a postural headache. The patient remained afebrile with stable vital signs. An EBP was performed in a sterile fashion, as described above, on postpartum day (PPD) 1 at the L2-L3 interspace with 20 mL autologous blood drawn in a sterile manner from a vein in the patient’s arm. The patient had full resolution of symptoms and was discharged to home on PPD2. Her headache recurred and was once again positional, and the patient returned on PPD4 for repeat EBP. The patient was afebrile, and her white blood cell count before the EBP was 8500 cells/μL with a normal differential consisting of 71% neutrophils, 23% lymphocytes, and 0.3% basophils. The procedure was repeated at the L3-L4 interspace in a sterile fashion, as described above, and the patient reported symptomatic improvement and was discharged to home later that day. On PPD5, the patient returned alert and oriented × 3, febrile to 38.6°C orally with a severe unrelenting nonpostural headache associated with nausea. Thirty minutes after arrival, the patient developed focal neurologic deficits, manifesting as expressive and receptive aphasia, as well as disorientation. A neurology and infectious disease consult was requested. Physical examination revealed nuchal rigidity with reflexive flexion of the legs. Examination of the back was unremarkable without any evidence of infection. Emergent computerized tomographic scan of the head was unremarkable without signs of infarct or hemorrhage. Laboratory results were significant for a white blood cell count of 18,900 cells/μL and 24% bands. Blood, urine, and cerebral spinal fluid (CSF) cultures were performed. The patient was empirically started on IV vancomycin, cefepime, ampicillin, acyclovir, and dexamethasone for suspected meningitis. Lumbar puncture results revealed a white blood cell count of 7790 cells/μL, protein 525 mg/dL, and glucose
