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Meningitis following spinal anaesthesia — a coincidental infection?
International Journal of Obsierric Anesthesia 0 1998 Hacourt
(1998) 7, 170-l 72
Brace and Co Ltd
CASE REPORT
Meningitis following spinal anaesthesia - a coincidental infection? T. Donnelly, M. Koper, S. Mallaiah Department of Anaesthesia, Liverpool Women’s Hospital, Liverpool, UK SUMMARY: We report a case of meningitis developing a number of days after a subarachnoid block for caesarean section, No organisms were grown but the clinical picture was suggestive of bacterial meningitis, the clinical course of which had been modified by the administration of antibiotics for presumed wound infection. The possible aetiology is discussed.
The operation was uneventful, a live female infant was delivered and the placenta was removed intact. A single dose of co-amoxiclav 1.2 g was administered intravenously during the operation as was routine in this hospital. The mother’s early recovery was unremarkable. Her temperature ranged from 36.9”C to 37.2”C and all her other observations were satisfactory. She was mobilizing well and breast feeding her baby. On the third postoperative day she was given rubella vaccination as she had been noted to be non-immune to rubella during the pregnancy. The following morning she felt unwell and had a temperature of 38.2”C. As the wound looked red and inflamed, oral co-amoxiclav 375 mg was given g-hourly for a presumed wound infection. A swinging pyrexia persisted for a further 24 h but returned to normal on the sixth postoperative day, and as all her observations were satisfactory, she was discharged home at her request on oral antibiotics. The following day, however, she became pyrexial again with a temperature of 38.2”C and a severe headache. Her antibiotic was changed by her general practitioner from co-amoxiclav to cefaclor 375 mg 12-hourly, but she remained unwell over the next 48 h. By the tenth postoperative day she was still complaining of severe headache and some photophobia and presented herself to the hospital with a temperature of 38.9”C. On examination she was found to have mild neck stiffness but Kernig’s sign was negative and no rash was noticed. Her white cell count was elevated at 12.9 x log/L with a neutrophilia of 11 x 109/L. A lumbar puncture was performed at the L3/4 interspace. The cerebrospinal fluid (CSF) was turbid with a white cell count of 139O/uL (70% polymorphs), red cell
CASE REPORT
A 36-year-old primigravida of 38 weeks’ gestation was admitted to the delivery suite in labour. Her membranes had ruptured an hour previously, draining clear liquor. A decision had been made antenatally to deliver her by caesarean section because of breech presentation. On admission, the presentation was still breech and it was decided to proceed with caesarean section forthwith. She was well, apyrexial and preferred to have regional anaesthesia for the operation. She was transferred to the operating theatre and given an intravenous fluid preload of Hartmann’s solution 1 L through a 16 gauge Venflon cannula placed in the back of her hand. Her back was then prepared with antiseptic spray consisting of 2.5% v/v (0.5% w/v) chlorhexidine in 70% alcohol which was within its expiry date, the area sprayed extending from about T5 to the sacral region. This was then allowed to dry while the anaesthetist, wearing no mask, scrubbed, gowned and gloved. A further application of the same disinfectant spray was applied and allowed to dry while the anaesthetist organized her equipment. She then identified the subarachnoid space at the L3/4 interspace with no difficulty using a 24 gauge pencil-point needle via an 18 gauge introducer. Thereafter, 2.5 ml of 0.5% heavy bupivacaine was administered producing a good bilateral block from T5 to S2 dermatomes. Asepsis was observed and all needles and syringes were disposable. Manuscript
accepted
August
1997
T. Donnelly, M. Koper, S. Mallaiah, Consultant Anaesthetist, Liverpool Women’s Hospital, Crown Street, Liverpool, UK.
Correspondence to S. Mallaiah. 170
Meningitis following spinal anaesthesia count of 3/uL and a protein level of 3.29 g/L. No organisms were seen on Gram stain of CSF film. The glucose level was not analysed as the sample was sent in an incorrect sample bottle. Ampicillin 3 g and cefotaxime 2 g intravenously S-hourly were started after CSF and blood samples were taken for culture. A diagnosis of meningitis was made and the patient was transferred to the care of the physicians. Incubation of blood, CSF, urine and throat swab samples yielded no growth. Chest X-ray was normal as was ultrasound examination of the abdomen. A magnetic resonance imaging scan of the lumbar spine showed no foci of infection. It did show a small disc prolapse at L4/5 level which was not impinging on any nerves. The patient made a full recovery and was discharged after 6 days.
DISCUSSION
Meningitis following central neural blockade is fortunately rare, but case reports of meningitis in association with spinal,‘-3 epidural,4J and most recently combined spinal-epidural anaesthesia, continue to appear in the literature.6 Drug-induced meningitis is a recognized problem in susceptible individuals.7 This patient’s symptoms did not appear until 4 days after the block, and she was pyrexial for more than 1 week. Even in the absence of CSF glucose analysis, aseptic meningitis in association with spinal anaesthesia can be reasonably excluded from the diagnosis by the time course of events - it usually has an acute onset within 24 h of the dural puncture and the symptoms subside rapidly without specific treatment. This complication was, in the past, put down to the use of detergent-contaminated syringes and needles causing a chemical irritation in the subarachnoid space.*-lo The use of disposable needles and syringes has presumably reduced its incidence. Our patient had received one dose of ranitidine 150 mg by mouth preoperatively. She was also given diclofenac 100 mg per rectum at the end of the operation. She received two further doses of rectal diclofenac, one each on the first two postoperative days. She started to feel unwell and developed a pyrexia on the fourth postoperative day. Hence druginduced meningitis can reasonably be excluded from the diagnosis. Our patient developed symptoms the day after rubella vaccination was administered. Mild reactions to rubella vaccination have been reported such as fever, arthralgia, sore throat, rash and lymphadenopathy. Very occasionally neurological symptoms have been reported but a causal relationship has not been established. The possibility that a vaccine may be
171
causative is reinforced if the timing of onset of the illness is similar to the known incubation period for the organism concerned. The incubation period for rubella is 14-21 days. The CSF analysis and time course of events exclude the vaccine from being implicated in this case. It may be that organisms were absent on Gram staining and after 48 h of incubation of CSF because antibiotics had been given for 6 days before the diagnostic lumbar puncture. Lee and Parry’ and Roberts and Petts* described cases of meningitis in two obstetric patients. In neither case was a causative organism identified. However, Lee and Parry pointed out that the pathogens involved in this type of introduced bacterial meningitis may be unusual and not easily identified by routine laboratory cultures. Kilpatrick and Girgis reviewed 17 cases of meningitis in patients who had received spinal anaesthesia and found that unusual and nosocomial organisms were commonly involved.3 This observation was borne out by other reports of meningitis in association with central neural blockade.& In the context of dural puncture, bacterial spread to the CSF may occur either via the blood stream or from contaminated equipment. Berman et al suggested that lumbar puncture created a site of low resistance for the passage of bacteria from the blood stream into the CSF after a bacteraemic episode.” Carp and Bailey demonstrated that dural puncture performed in bacteraemic rats was associated with a high incidence of meningitis but this risk was eliminated by antibiotic pre-treatment.12 There was nothing to suggest that our patient had a bacteraemia at the time of instituting spinal anaesthesia for caesarean section. Though the anaesthetist wore no mask, a sterile technique, which is mandatory for the institution of central blocks, was observed in all other respects. However, Sato et al demonstrated that in a large proportion of patients it is possible to isolate viable organisms from excised skin specimens after disinfection with 10% povidone iodine, and in a much smaller number of cases after disinfection with 0.5% chlorhexidine in 80% ethano1.r3 The disinfectant used in this case was 0.5% chlorhexidine in 70% ethanol and two applications were made and allowed to dry. It is not current policy in our hospital to wear face masks routinely for this purpose, and anaesthetists as a group nation-wide would appear to be divided as to whether face masks should be worn.14 This topic was debated at the 1997 meeting on Controversies in Obstetric Anaesthesia. Most of the arguments against wearing masks are invalid if a fresh mask is worn for each procedure. Moreover, a mask would avoid the
172 International Journal of Obstetric Anesthesia dissemination of bacteria that occurs while talking, which is necessary for the comfort and reassurance of the patient. l5 There has been at least one reported case of meningitis following accidental dural puncture where Streptococcus sanguis, a commensal mouth organism usually associated with dental caries, has been isolated from CSF culture.5 In summary, a previously healthy obstetric patient had uneventful spinal anaesthesia for caesarean section and developed fever 4 days later, which was treated with antibiotics. She went on to develop signs of meningitis which was treated as bacterial and she made a complete recovery. It was the opinion of the microbiologist consulted that the patient had a community-acquired meningitis which was unrelated to spinal anaesthesia. While it is possible that she had picked up the infection and was incubating the organisms before delivery, an interval of 4 days between spinal anaesthesia and onset of symptoms does not help one to decide whether this was a problem of subsequence or consequence.“j As the occurrence was uncomfortably close to the procedure, it is appropriate to consider this a rather dangerous complication of central neural blockade. As regional anaesthesia is becoming widely practised, it is important that anaesthetists do not drop their guard for the smallest moment and forget the meticulous care and attention to detail that is mandatory during these procedures.
REFERENCES 1. Lee J J , Parry H. Bacterial meningitis following spinal anaesthesia for caesarean section. Br J Anaesth 1991; 66: 383-386. 2. Roberts S P, Petts H V. Meningitis after obstetric spinal anaesthesia. Anaesthesia 1990; 45: 376377. 3. Kilpatrick M E, Girgis N I. Meningitis - a complication of spinal anesthesia. Anesth Analg 1983; 62: 513-515. 4. Davis L, Hargreaves C, Robinson P N. Postpartum meningitis. Anaesthesia 1993; 48: 788-789. 5. Berga S, Trierweiler M W. Bacterial meningitis following epidural anesthesia for vaginal delivery: a case report. Obstet Gynecol 1989; 74: 437438. 6. Harding S A, Collis R E, Morgan B M. Meningitis after combined spinal-extradural anaesthesia in obstetrics. Br J Anaesth 1994; 73: 545-547. 7. Burke D, Wildsmith J A W. Meningitis after spinal anaesthesia. Br J Anaesth 1997: 78: 635-636. 8. Bert A A, Laasberg L H. Aseptic meningitis following spinal anesthesia ~ a complication of the past? Anesthesiology 1985; 62: 674677. 9. Seigne T D. Aseptic meningitis following spinal analgesia. Anaesthesia 1970; 25: 402407. 10. Goldman W W, Sandford J P An ‘epidemic’ of chemical meningitis. Am J Med 1960; 29: 94-101. 11. Berman R S, Eisele J H. Bacteremia, spinal anesthesia and development of meningitis. Anesthesiology 1978; 48: 376377. 12. Carp H, Bailey S. The association between meningitis and dural puncture in bacteremic rats. Anesthesiology 1992; 76: 739-742. 13. Sato S, Sakuragi T, Dan K. Human skin flora as a potential source of epidural abscess.Anesthesiology 1996; 85: 1276-1282. 14. Panikkar K K, Yentis S M. Wearing of masks for obstetric regional anaesthesia. A postal survey. Anaesthesia 1996; 51: 398400. 15. Philips B J, Fergusson S, Armstrong P, Anderson F M, Wildsmith J A W. Surgical face masks are effective in reducing contamination caused by dispersal from the upper airway. Br J Anaesth 1992; 69: 407408. 16. Davies J M. Consequence versus subsequence: outcome after anaesthesia. Can Anaesth Sot J 1986; 33: 265-268.
(1998) 7, 170-l 72
Brace and Co Ltd
CASE REPORT
Meningitis following spinal anaesthesia - a coincidental infection? T. Donnelly, M. Koper, S. Mallaiah Department of Anaesthesia, Liverpool Women’s Hospital, Liverpool, UK SUMMARY: We report a case of meningitis developing a number of days after a subarachnoid block for caesarean section, No organisms were grown but the clinical picture was suggestive of bacterial meningitis, the clinical course of which had been modified by the administration of antibiotics for presumed wound infection. The possible aetiology is discussed.
The operation was uneventful, a live female infant was delivered and the placenta was removed intact. A single dose of co-amoxiclav 1.2 g was administered intravenously during the operation as was routine in this hospital. The mother’s early recovery was unremarkable. Her temperature ranged from 36.9”C to 37.2”C and all her other observations were satisfactory. She was mobilizing well and breast feeding her baby. On the third postoperative day she was given rubella vaccination as she had been noted to be non-immune to rubella during the pregnancy. The following morning she felt unwell and had a temperature of 38.2”C. As the wound looked red and inflamed, oral co-amoxiclav 375 mg was given g-hourly for a presumed wound infection. A swinging pyrexia persisted for a further 24 h but returned to normal on the sixth postoperative day, and as all her observations were satisfactory, she was discharged home at her request on oral antibiotics. The following day, however, she became pyrexial again with a temperature of 38.2”C and a severe headache. Her antibiotic was changed by her general practitioner from co-amoxiclav to cefaclor 375 mg 12-hourly, but she remained unwell over the next 48 h. By the tenth postoperative day she was still complaining of severe headache and some photophobia and presented herself to the hospital with a temperature of 38.9”C. On examination she was found to have mild neck stiffness but Kernig’s sign was negative and no rash was noticed. Her white cell count was elevated at 12.9 x log/L with a neutrophilia of 11 x 109/L. A lumbar puncture was performed at the L3/4 interspace. The cerebrospinal fluid (CSF) was turbid with a white cell count of 139O/uL (70% polymorphs), red cell
CASE REPORT
A 36-year-old primigravida of 38 weeks’ gestation was admitted to the delivery suite in labour. Her membranes had ruptured an hour previously, draining clear liquor. A decision had been made antenatally to deliver her by caesarean section because of breech presentation. On admission, the presentation was still breech and it was decided to proceed with caesarean section forthwith. She was well, apyrexial and preferred to have regional anaesthesia for the operation. She was transferred to the operating theatre and given an intravenous fluid preload of Hartmann’s solution 1 L through a 16 gauge Venflon cannula placed in the back of her hand. Her back was then prepared with antiseptic spray consisting of 2.5% v/v (0.5% w/v) chlorhexidine in 70% alcohol which was within its expiry date, the area sprayed extending from about T5 to the sacral region. This was then allowed to dry while the anaesthetist, wearing no mask, scrubbed, gowned and gloved. A further application of the same disinfectant spray was applied and allowed to dry while the anaesthetist organized her equipment. She then identified the subarachnoid space at the L3/4 interspace with no difficulty using a 24 gauge pencil-point needle via an 18 gauge introducer. Thereafter, 2.5 ml of 0.5% heavy bupivacaine was administered producing a good bilateral block from T5 to S2 dermatomes. Asepsis was observed and all needles and syringes were disposable. Manuscript
accepted
August
1997
T. Donnelly, M. Koper, S. Mallaiah, Consultant Anaesthetist, Liverpool Women’s Hospital, Crown Street, Liverpool, UK.
Correspondence to S. Mallaiah. 170
Meningitis following spinal anaesthesia count of 3/uL and a protein level of 3.29 g/L. No organisms were seen on Gram stain of CSF film. The glucose level was not analysed as the sample was sent in an incorrect sample bottle. Ampicillin 3 g and cefotaxime 2 g intravenously S-hourly were started after CSF and blood samples were taken for culture. A diagnosis of meningitis was made and the patient was transferred to the care of the physicians. Incubation of blood, CSF, urine and throat swab samples yielded no growth. Chest X-ray was normal as was ultrasound examination of the abdomen. A magnetic resonance imaging scan of the lumbar spine showed no foci of infection. It did show a small disc prolapse at L4/5 level which was not impinging on any nerves. The patient made a full recovery and was discharged after 6 days.
DISCUSSION
Meningitis following central neural blockade is fortunately rare, but case reports of meningitis in association with spinal,‘-3 epidural,4J and most recently combined spinal-epidural anaesthesia, continue to appear in the literature.6 Drug-induced meningitis is a recognized problem in susceptible individuals.7 This patient’s symptoms did not appear until 4 days after the block, and she was pyrexial for more than 1 week. Even in the absence of CSF glucose analysis, aseptic meningitis in association with spinal anaesthesia can be reasonably excluded from the diagnosis by the time course of events - it usually has an acute onset within 24 h of the dural puncture and the symptoms subside rapidly without specific treatment. This complication was, in the past, put down to the use of detergent-contaminated syringes and needles causing a chemical irritation in the subarachnoid space.*-lo The use of disposable needles and syringes has presumably reduced its incidence. Our patient had received one dose of ranitidine 150 mg by mouth preoperatively. She was also given diclofenac 100 mg per rectum at the end of the operation. She received two further doses of rectal diclofenac, one each on the first two postoperative days. She started to feel unwell and developed a pyrexia on the fourth postoperative day. Hence druginduced meningitis can reasonably be excluded from the diagnosis. Our patient developed symptoms the day after rubella vaccination was administered. Mild reactions to rubella vaccination have been reported such as fever, arthralgia, sore throat, rash and lymphadenopathy. Very occasionally neurological symptoms have been reported but a causal relationship has not been established. The possibility that a vaccine may be
171
causative is reinforced if the timing of onset of the illness is similar to the known incubation period for the organism concerned. The incubation period for rubella is 14-21 days. The CSF analysis and time course of events exclude the vaccine from being implicated in this case. It may be that organisms were absent on Gram staining and after 48 h of incubation of CSF because antibiotics had been given for 6 days before the diagnostic lumbar puncture. Lee and Parry’ and Roberts and Petts* described cases of meningitis in two obstetric patients. In neither case was a causative organism identified. However, Lee and Parry pointed out that the pathogens involved in this type of introduced bacterial meningitis may be unusual and not easily identified by routine laboratory cultures. Kilpatrick and Girgis reviewed 17 cases of meningitis in patients who had received spinal anaesthesia and found that unusual and nosocomial organisms were commonly involved.3 This observation was borne out by other reports of meningitis in association with central neural blockade.& In the context of dural puncture, bacterial spread to the CSF may occur either via the blood stream or from contaminated equipment. Berman et al suggested that lumbar puncture created a site of low resistance for the passage of bacteria from the blood stream into the CSF after a bacteraemic episode.” Carp and Bailey demonstrated that dural puncture performed in bacteraemic rats was associated with a high incidence of meningitis but this risk was eliminated by antibiotic pre-treatment.12 There was nothing to suggest that our patient had a bacteraemia at the time of instituting spinal anaesthesia for caesarean section. Though the anaesthetist wore no mask, a sterile technique, which is mandatory for the institution of central blocks, was observed in all other respects. However, Sato et al demonstrated that in a large proportion of patients it is possible to isolate viable organisms from excised skin specimens after disinfection with 10% povidone iodine, and in a much smaller number of cases after disinfection with 0.5% chlorhexidine in 80% ethano1.r3 The disinfectant used in this case was 0.5% chlorhexidine in 70% ethanol and two applications were made and allowed to dry. It is not current policy in our hospital to wear face masks routinely for this purpose, and anaesthetists as a group nation-wide would appear to be divided as to whether face masks should be worn.14 This topic was debated at the 1997 meeting on Controversies in Obstetric Anaesthesia. Most of the arguments against wearing masks are invalid if a fresh mask is worn for each procedure. Moreover, a mask would avoid the
172 International Journal of Obstetric Anesthesia dissemination of bacteria that occurs while talking, which is necessary for the comfort and reassurance of the patient. l5 There has been at least one reported case of meningitis following accidental dural puncture where Streptococcus sanguis, a commensal mouth organism usually associated with dental caries, has been isolated from CSF culture.5 In summary, a previously healthy obstetric patient had uneventful spinal anaesthesia for caesarean section and developed fever 4 days later, which was treated with antibiotics. She went on to develop signs of meningitis which was treated as bacterial and she made a complete recovery. It was the opinion of the microbiologist consulted that the patient had a community-acquired meningitis which was unrelated to spinal anaesthesia. While it is possible that she had picked up the infection and was incubating the organisms before delivery, an interval of 4 days between spinal anaesthesia and onset of symptoms does not help one to decide whether this was a problem of subsequence or consequence.“j As the occurrence was uncomfortably close to the procedure, it is appropriate to consider this a rather dangerous complication of central neural blockade. As regional anaesthesia is becoming widely practised, it is important that anaesthetists do not drop their guard for the smallest moment and forget the meticulous care and attention to detail that is mandatory during these procedures.
REFERENCES 1. Lee J J , Parry H. Bacterial meningitis following spinal anaesthesia for caesarean section. Br J Anaesth 1991; 66: 383-386. 2. Roberts S P, Petts H V. Meningitis after obstetric spinal anaesthesia. Anaesthesia 1990; 45: 376377. 3. Kilpatrick M E, Girgis N I. Meningitis - a complication of spinal anesthesia. Anesth Analg 1983; 62: 513-515. 4. Davis L, Hargreaves C, Robinson P N. Postpartum meningitis. Anaesthesia 1993; 48: 788-789. 5. Berga S, Trierweiler M W. Bacterial meningitis following epidural anesthesia for vaginal delivery: a case report. Obstet Gynecol 1989; 74: 437438. 6. Harding S A, Collis R E, Morgan B M. Meningitis after combined spinal-extradural anaesthesia in obstetrics. Br J Anaesth 1994; 73: 545-547. 7. Burke D, Wildsmith J A W. Meningitis after spinal anaesthesia. Br J Anaesth 1997: 78: 635-636. 8. Bert A A, Laasberg L H. Aseptic meningitis following spinal anesthesia ~ a complication of the past? Anesthesiology 1985; 62: 674677. 9. Seigne T D. Aseptic meningitis following spinal analgesia. Anaesthesia 1970; 25: 402407. 10. Goldman W W, Sandford J P An ‘epidemic’ of chemical meningitis. Am J Med 1960; 29: 94-101. 11. Berman R S, Eisele J H. Bacteremia, spinal anesthesia and development of meningitis. Anesthesiology 1978; 48: 376377. 12. Carp H, Bailey S. The association between meningitis and dural puncture in bacteremic rats. Anesthesiology 1992; 76: 739-742. 13. Sato S, Sakuragi T, Dan K. Human skin flora as a potential source of epidural abscess.Anesthesiology 1996; 85: 1276-1282. 14. Panikkar K K, Yentis S M. Wearing of masks for obstetric regional anaesthesia. A postal survey. Anaesthesia 1996; 51: 398400. 15. Philips B J, Fergusson S, Armstrong P, Anderson F M, Wildsmith J A W. Surgical face masks are effective in reducing contamination caused by dispersal from the upper airway. Br J Anaesth 1992; 69: 407408. 16. Davies J M. Consequence versus subsequence: outcome after anaesthesia. Can Anaesth Sot J 1986; 33: 265-268.