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Epidural blood patch with allogeneic blood for post-dural puncture headache
Correspondence 261 doi:10.1016/j.ijoa.2006.04.002
Epidural blood patch with allogeneic blood for post-dural puncture headache I have some concerns with regard to the paper of Cesur et al. reporting the use of allogeneic blood patches to treat post dural puncture headache.1 The United Kingdom has seen a significant outbreak of variant Creutzfeldt Jakob Disease (CJD) over the past 10 years with 161 cases. Smaller numbers of cases have also been seen in France (17), Ireland (4), the United States (2), Canada (1), Japan (1), Saudi Arabia (1), Spain (1), Portugal (1) and the Netherlands (1) [www.cjd.ed.ac.uk], pointing to the international dimension to this problem. Although the incidence of clinical cases of variant CJD in the United Kingdom appears to be diminishing, it is thought possible that the prevalence of sub-clinical disease may be one to two orders of magnitude higher.2 Moreover it is also now clear that such individuals can transmit variant CJD prions through blood components.3,4 Although the actual level of infectivity in peripheral blood during the incubation period in man remains uncertain, rodent studies suggest around 10 infectious doses (ID) per mL of whole blood (or 4500 ID/unit).5 Leuco-depletion and plasma reduction remove some infectivity, but sufficient is likely to remain to effect transmission if the donor is infected. Furthermore, although there is no evidence of transmission of sporadic or familial CJD by blood components, and the evidence on the presence of infectivity in the peripheral blood of such individuals is patchy, this possibility cannot be entirely excluded. Finally, it should be remembered that sporadic CJD has been transmitted iatrogenically by allogeneic dura mater grafts with a shorter incubation period than peripherally transmitted iatrogenic CJD.6 In summary I would urge caution in the use of allogeneic blood in this indication because it might provide a particularly effective route for transmission of prion disease if the donor happens to be harbouring sub-clinical prion infection. Clinicians should conduct a careful risk/benefit analysis balancing the potential prevalence of these diseases in their donor population against the nature and prognosis of the clinical condition they seek to manage. Marc Turner Chair, CJD Working Group of the UK Blood Services Specialist Advisory Committee in Transfusion Transmitted Infection, Scottish National Blood Transfusion Service, Edinburgh, UK E-mail: [email protected]
REFERENCES 1. Cesur M, Alici H A, Erdem A F, Yuksek M S. Epidural blood patch with allogeneic blood for post-dural puncture headache. Int J Obstet Anesth 2005; 14: 261–262.
2. Clarke P, Ghani A C. Projection of the future course of the variant CJD epidemic in the UK: incidence of subclinical infection and the possibility of wide genetic susceptibility. Journal of the Royal Society Interface 2005; 17: 1–13. 3. Llewelyn C A, Hewitt P E, Knight R S, et al. Possible transmission of variant Creutzfeldt-Jakob disease by blood transfusion. Lancet 2004; 363: 417–421. 4. Peden A H, Head M W, Ritchie D L, et al. Preclinical vCJD after blood transfusion in a PRNP codon 129 heterozygous patient. Lancet 2004; 364: 527–529. 5. Gregori L, McCombie N, Palmer D, et al. Effectiveness of leucoreduction for removal of infectivity of transmissible spongiform encephalopathies from blood. Lancet 2004; 364: 529–531. 6. Brown P, Preece M, Brandel J P, et al. Iatrogenic Creutzfeldt Jakob disease at the millennium. Neurology 2000; 55: 1075–1081.
doi:10.1016/j.ijoa.2006.04.003
In reply: Which risk is significant: the persistence of postdural puncture headache or epidural patch with allogeneic blood? Post dural puncture headache (PDPH) is not a simple complication. In addition to severe headache, nausea, vomiting, neck stiffness, ocular (photophobia, diplopia, difficulty accommodation) and auditory (hearing loss, hyperacusis, tinnitus) symptoms may be seen.1 All are distressing and can lead to significant morbidity and even death.2 It should not be forgotten that intracranial hypotension can result in intracranial hemorrhage from tearing of bridging meningeal veins.3 Postpartum seizures have been reported in eight women with PDPH.4 The incapacitating nature of this headache and other symptoms significantly impairs mother-infant bonding and the parturient’s ability to care for her newborn. In addition, prolonged bed rest may not be logical in the postpartum period because of the risk of deep venous thrombosis. Furthermore, headaches can persist for months after the puncture. So, delaying treatment can be extremely dangerous, and PDPH should not be treated lightly. If headache or other symptoms persist despite initial conservative treatment, epidural blood patch is an alternative for patients who are unable or unwilling to await spontaneous resolution of PDPH. If there is a contraindication to use autogenic blood for epidural patch, why not use allogeneic blood? Clearly, just as for any other therapy, the use of blood products is not a benign intervention and although it may proffer benefit, it always involves risk. The complete elimination of risk is impossible and the best way to avoid complications of transfusion is to avoid transfusion. However, sometimes blood product transfusion is unavoidable. Of over 10 million units of blood that are transfused per year in the United States, only 3.7% are autologous donations.5 Creutzfeldt-Jacob Disease is rare, with an annual incidence of 1 to 2 cases per million population.5 Transmission of the disease with blood products carries
Epidural blood patch with allogeneic blood for post-dural puncture headache I have some concerns with regard to the paper of Cesur et al. reporting the use of allogeneic blood patches to treat post dural puncture headache.1 The United Kingdom has seen a significant outbreak of variant Creutzfeldt Jakob Disease (CJD) over the past 10 years with 161 cases. Smaller numbers of cases have also been seen in France (17), Ireland (4), the United States (2), Canada (1), Japan (1), Saudi Arabia (1), Spain (1), Portugal (1) and the Netherlands (1) [www.cjd.ed.ac.uk], pointing to the international dimension to this problem. Although the incidence of clinical cases of variant CJD in the United Kingdom appears to be diminishing, it is thought possible that the prevalence of sub-clinical disease may be one to two orders of magnitude higher.2 Moreover it is also now clear that such individuals can transmit variant CJD prions through blood components.3,4 Although the actual level of infectivity in peripheral blood during the incubation period in man remains uncertain, rodent studies suggest around 10 infectious doses (ID) per mL of whole blood (or 4500 ID/unit).5 Leuco-depletion and plasma reduction remove some infectivity, but sufficient is likely to remain to effect transmission if the donor is infected. Furthermore, although there is no evidence of transmission of sporadic or familial CJD by blood components, and the evidence on the presence of infectivity in the peripheral blood of such individuals is patchy, this possibility cannot be entirely excluded. Finally, it should be remembered that sporadic CJD has been transmitted iatrogenically by allogeneic dura mater grafts with a shorter incubation period than peripherally transmitted iatrogenic CJD.6 In summary I would urge caution in the use of allogeneic blood in this indication because it might provide a particularly effective route for transmission of prion disease if the donor happens to be harbouring sub-clinical prion infection. Clinicians should conduct a careful risk/benefit analysis balancing the potential prevalence of these diseases in their donor population against the nature and prognosis of the clinical condition they seek to manage. Marc Turner Chair, CJD Working Group of the UK Blood Services Specialist Advisory Committee in Transfusion Transmitted Infection, Scottish National Blood Transfusion Service, Edinburgh, UK E-mail: [email protected]
REFERENCES 1. Cesur M, Alici H A, Erdem A F, Yuksek M S. Epidural blood patch with allogeneic blood for post-dural puncture headache. Int J Obstet Anesth 2005; 14: 261–262.
2. Clarke P, Ghani A C. Projection of the future course of the variant CJD epidemic in the UK: incidence of subclinical infection and the possibility of wide genetic susceptibility. Journal of the Royal Society Interface 2005; 17: 1–13. 3. Llewelyn C A, Hewitt P E, Knight R S, et al. Possible transmission of variant Creutzfeldt-Jakob disease by blood transfusion. Lancet 2004; 363: 417–421. 4. Peden A H, Head M W, Ritchie D L, et al. Preclinical vCJD after blood transfusion in a PRNP codon 129 heterozygous patient. Lancet 2004; 364: 527–529. 5. Gregori L, McCombie N, Palmer D, et al. Effectiveness of leucoreduction for removal of infectivity of transmissible spongiform encephalopathies from blood. Lancet 2004; 364: 529–531. 6. Brown P, Preece M, Brandel J P, et al. Iatrogenic Creutzfeldt Jakob disease at the millennium. Neurology 2000; 55: 1075–1081.
doi:10.1016/j.ijoa.2006.04.003
In reply: Which risk is significant: the persistence of postdural puncture headache or epidural patch with allogeneic blood? Post dural puncture headache (PDPH) is not a simple complication. In addition to severe headache, nausea, vomiting, neck stiffness, ocular (photophobia, diplopia, difficulty accommodation) and auditory (hearing loss, hyperacusis, tinnitus) symptoms may be seen.1 All are distressing and can lead to significant morbidity and even death.2 It should not be forgotten that intracranial hypotension can result in intracranial hemorrhage from tearing of bridging meningeal veins.3 Postpartum seizures have been reported in eight women with PDPH.4 The incapacitating nature of this headache and other symptoms significantly impairs mother-infant bonding and the parturient’s ability to care for her newborn. In addition, prolonged bed rest may not be logical in the postpartum period because of the risk of deep venous thrombosis. Furthermore, headaches can persist for months after the puncture. So, delaying treatment can be extremely dangerous, and PDPH should not be treated lightly. If headache or other symptoms persist despite initial conservative treatment, epidural blood patch is an alternative for patients who are unable or unwilling to await spontaneous resolution of PDPH. If there is a contraindication to use autogenic blood for epidural patch, why not use allogeneic blood? Clearly, just as for any other therapy, the use of blood products is not a benign intervention and although it may proffer benefit, it always involves risk. The complete elimination of risk is impossible and the best way to avoid complications of transfusion is to avoid transfusion. However, sometimes blood product transfusion is unavoidable. Of over 10 million units of blood that are transfused per year in the United States, only 3.7% are autologous donations.5 Creutzfeldt-Jacob Disease is rare, with an annual incidence of 1 to 2 cases per million population.5 Transmission of the disease with blood products carries