Dural 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.
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.
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 <20 mg/dL, consistent with bacterial meningitis. Magnetic resonance imaging of the lumbar spine with contrast did not show an epidural mass or collection, and there was no evidence of arachnoiditis.
Blood cultures were positive for GBS sensitive to ampicillin, and she was transitioned to IV ampicillin as the sole antibiotic. CSF cultures were negative. The patient completed a 14-day course of IV antibiotic therapy, during which time she made a complete recovery and was discharged to home.
GBS is a known maternal pathogen and if left untreated is a leading cause of neonatal morbidity and mortality. A variety of maternal GBS infections may occur in the course of pregnancy and the postpartum period. Apart from cervicovaginal colonization, which is usually asymptomatic, GBS can cause urinary tract infections, vulvovaginitis, intra-amniotic infection, mastitis, bacteremia, sepsis, meningitis, endometritis, and wound infections.1
Peripartum meningitis is a rare event. Reynolds identified 41 published reports on peripartum meningitis, and dural puncture was present in most cases but not all.2 There are 2 case reports of GBS meningitis after uncomplicated epidural analgesia, and in both the authors attributed the meningitis to preexisting colonization with GBS. In the first case,3 the patient was not tested for GBS before labor, had an uncomplicated epidural catheter placed, and had an episiotomy for a vaginal delivery, similar to our patient. Forty-two hours after delivery, the patient developed a headache, a fever of 38.8°C, and clinical signs consistent with meningitis including neck stiffness and confusion. Antibiotics were started before lumbar puncture, and the CSF culture was negative but the blood culture, similar to our case, was positive for GBS. In the second case,4 the patient was treated with 4 weeks of ampicillin at 30 weeks’ gestation for a vaginal GBS infection and then for 2 weeks with amoxicillin at 36 weeks’ gestation for bronchitis. She had 2 epidural catheters placed during labor, both placed without evidence of dural puncture, and she underwent a cesarean delivery due to failure to progress in the 2nd stage of labor. Postoperatively, she developed endometritis and pneumonia treated with ampicillin/sulbactam. On postoperative day 6, she developed a fever and signs of meningitis including a fever. All blood and CSF cultures were negative, and she recovered after treatment with antibiotics. The authors attributed the meningitis to the epidural catheter placements. Labor may be a specific risk factor for peripartum meningitis, occurring in 35 of the 41 published cases.2 Vaginal trauma, as is typical with many vaginal deliveries, may be a predisposing factor for bacteremia as occurred in our case and in one of the other cases of GBS meningitis.3
Meningitis after EBP is also extremely rare, and we are aware of only 2 other reported cases of meningitis after EBP.5,6 In the first case, Streptococcus sanguis,5 a bacterial inhabitant commonly found in the mouth was cultured from the CSF; in the latter, Staphylococcus epidermidis, a skin pathogen, was the culprit.6
The mechanism by which the GBS was introduced into the neuraxis in our patient is unclear; it may have been by either an exogenous or a hematogenous mechanism. Exogenous contamination may have occurred from a breakdown in sterile technique during the epidural procedures. We do not believe this is the case because GBS is neither a skin contaminant nor a common nasal/oral bacterium, and meticulous sterile technique was observed. Hematogenous contamination seems more likely. Approximately 25% of all pregnant women are colonized with GBS in the vagina or rectum7; the American College of Obstetrics and Gynecology therefore recommended that pregnant patients be screened for GBS before delivery.8 The incidence of GBS bacteriuria is approximately 1%,9 but the incidence of maternal bacteremia is much lower and has been estimated at approximately 1 in 500 GBS+ patients.10 If the woman is GBS positive, she is treated with antibiotics during labor to prevent vertical transmission to the newborn, but this dose does not adequately treat the mother. Our patient was given antibiotic prophylaxis, ampicillin 2 g IV repeated 4 hours later, during labor. With labor and vaginal trauma, it is possible the patient experienced GBS bacteremia. Our patient had a mediolateral episiotomy, which increased the vaginal trauma compared with a delivery without an episiotomy, perhaps further increasing her risk. It is possible that during one of the epidural procedures, contaminated blood was introduced into the neuraxis. The temporal onset of symptoms related to the second EBP highly suggests that this EBP procedure was the inciting event. It is conceivable that contaminated blood from an otherwise asymptomatic patient was drawn from the patient’s arm and introduced into the neuraxis.
We can only presume that the meningitis was secondary to GBS because this was the putative agent that was detected in the serum although the CSF culture was negative. It is possible that the CSF culture was falsely negative because the patient received antibiotic treatment before the CSF culture,11 but the administration was 4 days before the culture, making this possibility less likely. It is more likely that the culture simply failed to grow the GBS, that is, it was falsely negative, which has been reported to occur in up to 23% of patients with bacterial meningitis.12 The CSF glucose and protein concentrations were highly suggestive of meningitis, and these variables are more sensitive than the bacterial culture.12 It has been suggested that a blood sample for culture be obtained before all EBP procedures in case the patient develops meningitis so that the correct antibiotic can be immediately started.13,14 However, this is neither practical nor cost-effective because the complication is extremely rare.
Once the presumptive diagnosis of meningitis was made, the patient was started on broad spectrum antibiotics to cover both hospital and community-acquired meningitis. We started antibiotics with the objective of treating bacterial meningitis, herpes simplex encephalitis, methicillin-resistant Staphylococcus aureus, and Listeria. Once the blood culture was positive for GBS, the ampicillin was continued and the other antibiotics discontinued.
EBP has become the standard treatment in patients with postdural puncture headache. This case demonstrates the need to consider other causes of headache in the postpartum period. Meningitis, although rare, should always be considered in the differential diagnosis. Rapid recognition and prompt treatment, as well as communication among the anesthesiologists, obstetricians, neurologists, and infectious disease specialists, resulted in a positive outcome for this patient.
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