Severe, Acute Meningeal Irritative Reaction After Epidural Blood Patch

Abstract

Epidural blood patch (EBP) is considered to be a safe and effective treatment for the symptomatology of postdural puncture headache (PDPH) [1]. Adverse sequelae of this treatment are infrequent, with transient low back pain the most common complaint. Infectious complications are rare, and reports of aseptic meningitis after EBP are lacking. We present a case of acute, severe meningeal irritation that occurred after an EBP. Case Report The patient was a 30-yr-old gravida 2, para 1 at term gestation scheduled for a primary cesarean delivery because of fetal macrosomia (estimated fetal weight 4310 g). Her medical history was significant for noninsulin-dependent diabetes diagnosed during the first pregnancy 6 yr previously and treated with insulin only during the current pregnancy. Hypothyroidism and obesity (165 cm, 153 kg) were additional considerations. She had a previous vaginal delivery of a macrosomic infant who died on the second day of life because of sequelae of birth trauma. The administration of spinal anesthesia was difficult, requiring multiple needle insertions by several anesthesiologists using an 8.89-cm, 25-gauge Whitacre needle. Ultimately, a 22-gauge Quincke point needle was inserted at the L2-3 spinal interspace, and a mixture of 12 mg of hyperbaric bupivacaine (8.25% dextrose), 10 [micro sign]g of fentanyl, and 200 [micro sign]g of epinephrine was injected. A bilateral sensory level to T4 was obtained. Cesarean delivery was uncomplicated, and a male infant was delivered with Apgar scores of 8 and 9. On Postoperative Day (POD) 1, the patient complained of a headache that worsened when standing and eased, although did not completely resolve, in the supine position. Conservative therapy was initiated, consisting of bed rest, IV fluid hydration, and oral oxycodone and acetaminophen for pain. The intensity of headache decreased somewhat with therapy, but symptoms persisted into PODs 2 and 3, increasing in intensity without neurologic symptoms except for the complaint of occasional black spots moving before the patient's eyes. At this time, an EBP was offered as treatment, but the patient refused, recalling discomfort from her previous experience during a difficult spinal anesthesia placement. On POD 4, symptoms had not changed; on POD 5, the patient finally agreed to have an EBP. One hour before the EBP, the patient's oral temperature was 99.9[degree sign]F with no other signs of infection. The surgical incision was healing well, and there were no signs of mastitis, deep venous thrombosis, or urinary tract or upper respiratory infection. An iv infusion was started, and midazolam 1 mg and fentanyl 50 [micro sign]g were given for sedation. The back was cleansed with betadine, wiped dry, and the epidural space identified on the second attempt with loss of resistance using sterile isotonic sodium chloride solution via a 17-gauge Weiss needle. Autologous blood, 20 mL (drawn in a sterile manner from an antecubital vein), was injected into the epidural space without discomfort. The patient was placed supine, and, during next hour, symptoms of PDPH improved when the patient assumed an upright posture. Approximately 2.5 h after the EBP, the patient complained of chills and had an oral temperature of 102.5[degree sign]F. Arterial blood pressure was 143/70 mm Hg, heart rate was 88 bpm, and respiratory rate was 24 breath/min with an oxygen saturation of 96% while breathing room air. She was evaluated by the obstetric service and given oxycodone and acetaminophen for headache and fever. Approximately 4.5 h after EBP the patient had a fever of 102.8[degree sign]F and complained of worsening headache, photophobia, and nuchal rigidity. She was nauseated and appeared to be tremulous and anxious. No focal neurologic signs could be elicited. Fundoscopic examination by a neurologist showed no evidence of increased intracranial pressure. A diagnosis of acute meningitis was considered. Lumbar puncture using a 22-gauge, 5-inch Quincke needle was performed with moderate difficulty (because of the patient's obesity), and cerebrospinal fluid samples and blood and urine cultures were sent for analysis before initiating a regimen of IV antibiotics consisting of vancomycin and cefotaxime, as well as the analgesics ibuprofen and oxycodone and acetaminophen. The serum white cell count was 9.3 k/mL. Twelve hours after EBP, her oral temperature was 100.1[degree sign]F. The headache was gone in the supine position, although it was present mildly when she stood up. Her neck stiffness was nearly resolved. Subsequently, the patient continued to improve and was discharged home on POD 8. Cerebrospinal fluid (CSF) analysis showed 2600 white blood cells and 19300 red blood cells in the first tube, and 2000 white blood cells and 14000 red blood cells in the fourth tube. The final CSF and urine cultures were negative for bacterial growth. Gram staining of CSF showed no evidence of bacteria. One of four blood culture bottles grew Staphylococcus aureus, and the patient was continued on IV antibiotics at home to complete a 14-day course of therapy. She recovered completely with no further sequelae. Discussion The most common complication associated with EBP is transient back pain [2]. Other complications include lumbovertebral syndrome [3], radicular pain [4,5], transient bradycardia [6], cranial and facial nerve palsies related to the headache [1], transient increases in body temperature [1], and seizure [7]. Although aseptic meningitis has not been reported as a complication of EBP, there have been studies on the effects of epidurally injected blood after simple dural puncture. DiGiovanni et al. [8] injected 2 mL of autologous blood in goats and found that the CSF tissue reaction differed little from that of the control group with a non-injected dural puncture. Magnetic resonance imaging of epidurally injected blood shows that the blood does spread into the subarachnoid space and paravertebral tissues [9,10]. However, arachnoiditis or chemical meningitis due to epidural injection of autologous blood has not been reported. This was reinforced by an animal study, which showed no meningeal irritation and temperature increase when fresh autologous blood was injected intracisternally in dogs [11]. Interestingly, that study revealed that when 1-2 mL of 1- to 2-day-old blood was injected intracisternally, the dogs had increases in temperature and signs of meningeal irritation. Furthermore, severe aseptic meningitis occurred after the injection of incubated blood >3 days old. Our patient had symptoms and signs of acute meningeal irritation after an EBP. Although the possibility of bacterial meningitis was considered, resolution of symptoms within approximately 12 h of onset makes this an unlikely diagnosis; growth of Staphylococcus aureus from only one of four blood cultures most likely represents contaminant. However, one must consider the possibility that 5-day-old blood that may have been present in the epidural space from the previous difficult spinal anesthetic being introduced into the subarachnoid space during EBP may have been the source of the meningeal irritation. The decision to perform EBP in the presence of a low-grade (99.9[degree sign]F) fever may be questioned. The patient had no signs of systemic or focal infection, and clearly had severe PDPH, with signs of cranial nerve involvement that was not responding to conservative therapy. For these reasons, we elected to proceed. Other treatment options for PDPH may be considered if an EBP seems to be difficult or is relatively contraindicated. For example, caffeine administration may be offered, although this treatment rarely provides long-lasting relief [12]. The use of adrenocorticotropic hormone therapy [13] has been suggested and may prove useful in some circumstances, but we elected not to use that modality because of the patient's diabetes. In summary, we report an instance of acute, severe meningeal irritation after EBP that resolved over a 24-h period. The cause was possibly related to the irritant effects of residual blood in the epidural space, which may have contributed to the low-grade fever noted before EBP. Aseptic meningitis should be considered in the differential diagnosis of headache and other infectious symptoms after otherwise uncomplicated EBP.