Meningitis following spinal anesthesia

[Downloaded free from http://www.mjdrdypu.org on Wednesday, September 28, 2016, IP: 83.162.160.233]

Case Report

Meningitis following spinal anesthesia Balasaheb T. Govardhane, Tejaswini C. Jambotkar, Jyoti S. Magar, Bharati A. Tendolkar Department of Anaesthesiology, LTMMC and LTMG Hospital, Sion, Mumbai, Maharashtra, India

Access this article online

ABSTRACT Iatrogenic meningitis is a rare, but potentially fatal condition. We report four cases of meningitis after spinal anesthesia and review the possible etiological factors of post spinal meningitis. An important cause include mainly break in sterile technique with direct introduction of bacteria. However, usually clustering of cases by single anesthesiologist is reported. We report a series of cases in short duration by different anesthesiologists’ in different operation theatres of the same hospital even with maximum sterile barrier. The difficulty in differentiation between aseptic and bacterial meningitis is noted. Finally, since delay in the diagnosis may result in morbidity and mortality, it is crucial to rule out rarest of the causes with thorough investigations and high index of suspicion. Keywords: Etiological factors, meningitis, spinal anesthesia

Introduction Iatrogenic meningitis after spinal anesthesia is an extremely rare but serious complication. It can occur in various settings including spinal anesthesia, diagnostic lumbar puncture, myelography, epidural analgesia and anesthesia, neurological procedures involving spinal canal. The exact incidence of infectious complication associated with epidural and spinal anesthesia is unknown. However several retrospective studies have estimated it as being very low from 0% to 0.04%.[1] Two important causes of post spinal meningitis are breach in aseptic techniques or hematogeneous spread in presence of asymptomatic bacteremia during lumbar puncture. Primary contamination of equipment’s and anesthetic drugs as a cause is less likely.

Case Report We report four cases which developed meningitis after spinal anesthesia was given for surgical procedures. A 24 years female with 27 weeks gestation for cervical

Quick Response Code:

Website: www.mjdrdypu.org

DOI: *********

encirclage, 60 years female for skin grafting over left thigh, 35 years male for hemorroidectomy and a 26 years female with previous caesarean section lower segment caesarean section (LSCS) for elective LSCS. All the patients were ASA I with no symptoms and signs suggestive of underlying systemic infection. Complete blood count was within normal limits. All cases occurred over a period of 1-week, in different operation theatres by different anesthesiologists. Spinal anesthesia was given under standard strict aseptic precautions which included wearing cap, face mask, sterile gown, sterile hand gloves, cleansing agent (povidone iodine and alcohol) and sterile drape. The spinal needle and drug (hyperbaric 0.5% bupivacaine) used by all the anesthesiologist belonged to the same company and batch. All the four patients first complained of headache approximately 6-8 h after administration of spinal anasthesia. One patient also developed vomiting. The pregnant patient developed altered sensorium 10 h after spinal anesthesia. The chief complaint headache was not relieved in supine position or with adequate hydration and analgesia. Thus, postdural puncture headache was ruled out and physician reference was taken. Over next 4-6 h all patients developed fever (37.4°C-38°C), neck rigidity and positive Kerning’s sign. Therefore, fundoscopy, followed by urgent cerebrospinal fluid (CSF) examination and computed tomography scan was done for all patients. The findings were suggestive of cerebral edema. Fundoscopy did not show any evidence of papilledema. CSF picture was suggestive of

Address for correspondence: Dr. Tejaswini C. Jambotkar, Department of Anaesthesiology, 4th Floor, College Building, LTMMC and LTMGH, Sion, Mumbai - 400 022, Maharashtra, India. E-mail: [email protected] Medical Journal of Dr. D.Y. Patil University | July-August 2015 | Vol 8 | Issue 4

513

[Downloaded free from http://www.mjdrdypu.org on Wednesday, September 28, 2016, IP: 83.162.160.233] Govardhane, et al.: Post spinal meningitis

bacterial meningitis though Gram-staining and culture was negative. Total white blood cell count was raised, but blood culture was negative. Lumbar puncture showed turbid CSF and revealed the picture shown in Table 1. On the basis of clinical findings and CSF picture all the patients were strongly suspected to have bacterial meningitis. Treatment in the form of injection vancomycin, ceftriaxone and ampicillin was instituted on emergency basis. All patients rapidly improved with treatment and were discharged after 7 days without any neurological sequelae.

Discussion Bacterial meningitis is an acute purulent infection within subarachnoid space. The possible causes include break in sterile technique with direct introduction of bacteria, hematogenous spread with microscopic bleeding during spinal anesthesia in septicemic patients and a less likely cause is primary contamination of equipment and anesthesia drugs. [2,3] Various strains of Streptococcus which are commensals of oral cavity and respiratory tract are the dominant causative organisms although culture may be frequently negative. Most organisms are of low virulence and hence fastidious growth is not seen on routine culture medium but in CSF they multiply rapidly causing full blown bacterial meningitis in 7-24 h. But usually clustering of cases by single anesthesiologist is reported.[4] Droplet infection from patient itself or medical person and needle contamination from incompletely sterilized skin are major routes of infection. To pinpoint exact source one needs to compare isolates from nasal or nasopharyngeal swab of patient and medical person with that of patients CSF.[5] Thus, a sterile technique including tightly fitting face mask covering mouth and nose is essential. Meningitis should be a possible differential diagnosis in patient having postdural puncture headache, convulsion or

altered neurological status. Suspicion should immediately trigger collection of blood and CSF for culture and analysis. Empirical broad spectrum antimicrobial and adjuvant therapy should be given in an appropriate clinical setting. In a scenario of strong clinical suspicion treatment should not be delayed awaiting for reports. The etiology of postdural puncture meningitis is very debatable. The hematogenous spread of infection with micro bleeding during spinal anaesthesia is extremely rare. [6] In recent reviews, presence of bacteremia is a relative contraindication to central neuraxial block. [7,8] Antibiotic prophylaxis in a bacteremic patient is advised before puncture and mandates close observation postoperatively. Every case requires thorough consideration to all etiological factors including equipment, drug, and technique. Modern packaging for equipment and drug has almost eliminated these issues. But still sporadic cases like ours suggest need for attention and reevaluation of causative factors. Purulent CSF but no growth on culture may be because of prior administration of antibiotic or other causes like viral or aseptic meningitis. Aseptic meningitis can either be due to chemical contamination of CSF or less widely appreciated systemic drug administration. nonsteroidal anti-inflammatory drug and H2 antagonists cause aseptic meningitis due to acute hypersensitivity reaction. [9] Signs and symptoms such as headache, convulsion or altered neurological status appear typically from few hours to weeks. Fever is common. CSF picture is same as bacterial meningitis except that the CSF glucose is normal. Symptoms worsen with continued drug administration, but most patients recover after offending medication is stopped. Definitive diagnosis requires re-administration of drug. In our cases, there was no significant drug history which ruled out this possibility in patients with the mentioned CSF picture though the sugar was normal.

Table 1: Results of CSF examination Parameters WBCs (/mm3) RBCs (/mm3) Glucose (mg/dl) CSF/serum glucose ratio Proteins (mg/dl) Gram-stain % Culture %

Case 1 (%) 576 (P-90, L-10)

Case 2 (%) 322 (P-70, L-30)

Case 3 (%) 1862 (P-80, L-20)

· 94 0.52

Occasional 52 0.34

Occasional 50 0.4

533 Negative Negative



Case 4 (%) Bacterial meningitis 1528 (P-95, L-5) 10-10000, neutrophil predominant 15-20 Absent 15 60 Positive >80

Aseptic meningitis 500-600, lymphocyte predominant Absent 40-70 º0.6

Normal (%) 0-5 (L-60-70, M-30-50) 0 40-70 º0.6

>50 Negative Negative

15-50 Negative Negative

CSF: Cerebrospinal fluid, WBC: White blood cell, RBC: Red blood cell

514

Medical Journal of Dr. D.Y. Patil University | July-August 2015 | Vol 8 | Issue 4

[Downloaded free from http://www.mjdrdypu.org on Wednesday, September 28, 2016, IP: 83.162.160.233] Govardhane, et al.: Post spinal meningitis

Cerebrospinal fluid glucose concentrations