Bacterial sacroiliitis probably induced by lumbar epidural analgesia - PDF Document

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  1. Color profile: Disabled Composite Default screen Infect Dis Obstet Gynecol 2003;11:105–108 Bacterial sacroiliitis probably induced by lumbar epidural analgesia Shimon Edelstein and Yeouda Edoute Department of Internal Medicine C, Rambam Medical Center and the Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Background: Properly administered, lumbar epidural analgesia provides adequate pain relief during labor and delivery, and is considered to be a safe procedure with limited complications. The prevalence of infection after lumbar epidural analgesia is negligible. Introduction: Infectionofthesacroiliacjoint,althoughveryclosetothepucturearea,hasneverbeenreportedas a procedure complication. Case: In this report, we describe a patient who experienced bacterial sacroiliitis a few days after lumbar epidural analgesia for labor. No portal of entry was identified, and we evoked a new potential risk factor that has never been proposed before, namely lumbar epidural analgesia. Conclusion: Sacroiliitis must be considered as a rare but serious complication of lumbar epidural analgesia. Key words: COMPLICATION; OSTEOMYELITIS; BONE SCAN; LUMBAR PUNCTURE CASE buttock pain. Over the next day the pain increased in intensity until she was unable to bear weight on her right leg. She was then hospitalized for evaluation. Her past medical history was un- remarkable except for allergy to penicillin, manifested by skin rash. She denied a history of trauma or drug use. Onphysicalexamination,shehadatemperature of 40°C, pulse rate of 116 beats/minute, respira- tory rate of 24 breaths/minute, and blood pressure of 90/60 mmHg. She had severe pain over the right sacroiliac joint posteriorly, and pelvic compression elicited severe pain in the right sacroiliac joint. Gynecological and neurological examinations were unremarkable. Thepatient’slaboratorytestresultsweresignifi- cant for an elevated erythrocyte sedimentation rate (ESR) of 115 mm/hour and leukocytosis of 11 100 cells/mm3with left shift. Three bottles of A 25-year-old woman delivered a healthy baby under lumbar epidural analgesia and was dis- charged home in good condition and with a normal temperature. The delivery was undertaken atadifferenthospital,butaccordingtothedescrip- tiononthedischargefile,boththedeliveryandthe lumbar epidural analgesia were normal without the need for instrumentation, evidence of soft tissue trauma or vaginal wall tears or any other complication.Noinjectionsweregivenapartfrom the epidural analgesia. According to the patient’s chart the lumbar epidural analgesia was described as ‘usual with no complications’, at L3-L4 inter- vertebral space, using an 18-gauge needle to penetrate and bupivacaine as an analgesic medica- tion. Five days after discharge, the patient experi- enced fever (39.5°C) and chills, malaise and right Correspondence to: Shimon Edelstein, MD, Department of Internal Medicine C, Rambam Medical Center, PO Box 9602, 31096 Haifa, Israel. Email: s_edelstein@rambam.health.gov.il  2003 The Parthenon Publishing Group 105 37 Z:\Customer\PARTHEN\IDOG\A4577 - IDOG Vol 11 No 2 - June 2003.vp 09 July 2003 14:29:40

  2. Color profile: Disabled Composite Default screen Bacterial sacroiliitis Edelstein and Edoute blood cultures were obtained in the initial hours after arrival, prior to antibiotic initiation. The patient refused to undergo aspiration, even though the staff made an effort to explain the importance of pathogen isolation in order to narrow the antibiotic spectrum and minimize the side-effects. The blood cultures that were taken prior to and during the antibiotic treatment demonstrated no growth. Chest X-ray, plain roentgenograms and computed tomography (CT) of the pelvis and lumbosacral spine were normal on admission. Technetium-99 methylene diphosphonate (Tc-99m MDP) bone scintigraphy demonstrated mildly increased uptake in the right sacroiliac region (Figure 1). Gallium scintigraphy demonstrated increased uptake of Ga-67 citrate in the right sacroiliac region. The uptake was greater with regard to area and intensity compared with the bone scan (Figure 2). These findings suggested a diagnosis of acute infectious right sacroiliitis. Septic arthritis of the sacroiliac joint was suspected, and a regimen of intravenous vanco- mycin 1 g every 12 hours and gentamicin 80 mg every 8 hours was administered. Within 48 hours the patient’s fever responded, and after 10 days she noticed decreased pain. On day 12 gentamicin was stopped because of nephrotoxicity despite desirable gentamicin levels (pre- and post- administration) on hospitalization days 3 and 7. After 17 days of therapy the patient was sacroiliac joint Figure 2 hours after intravenous injection of Ga-67 citrate demonstrating increased uptake of the tracer in the right sacroiliac region (arrow). The uptake was greater with regard to intensity and area compared with the bone scan. The findings are consistent with right sacroiliitis Gallium scintigraphy (posterior view) 24 Figure 1 after intravenous injection of 24 mCi of Tc99m-MDP demonstrates mildly increased uptake of the tracer in the right sacroiliac region (arrow) Bone scintigraphy (posterior view) 2 hours 106 • INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 38 Z:\Customer\PARTHEN\IDOG\A4577 - IDOG Vol 11 No 2 - June 2003.vp 09 July 2003 14:29:42

  3. Color profile: Disabled Composite Default screen Bacterial sacroiliitis Edelstein and Edoute ambulatory, and she continued to show steady improvement thereafter. No bone scan or gallium scan was repeated, since the patient felt much better and refused to undergo further examina- tions. She was discharged home after 28 days of hospitalization,andaregimenoforalfucidinicacid and ofloxacin was recommended for 2 weeks. Eight weeks after discharge the patient had recovered completely and her ESR had returned to normal. the present patient suggested a diagnosis of acute infectious right sacroiliitis. Needle aspiration of the suspected infected bone is highly recom- mended, as a wide spectrum of pathogens may infect the bone and thus a wide spectrum of anti- biotic coverage must be given, if no pathogen is isolated. Since a specific pathogen was not isolated in this case, empirical broad-spectrum antibiotic therapy with vancomycin and gentamicin was directed toward Staphylococcus aureus and Gram- negative bacteria, and resulted in complete recovery 8 weeks after discharge of the patient. Lumbar epidural analgesia is considered to be a safe procedure with limited complications14. In a reviewofthematernalcomplicationsinaconsecu- tive series of over 27 000 instances of lumbar epidural analgesia used during labor, Crawford15 reported only one case of infection, in which lumbar epidural analgesia given to a woman was complicated by occult streptococcal bacteremia. Source investigation yielded a small infected hematoma in the epidural space15. Bacterial sacroiliitis usually occurs in patients with under- lying conditions such as trauma, a history of intravenous drug abuse or a concurrent source of bacterial infection6,10–13. In the present case, the presentation of bacterial sacroiliitis 5 days after delivery under lumbar epidural analgesia and the absence of an underlying condition suggest that in this woman the bacterial sacroiliitis could be attributed to the lumbar epidural analgesia procedure during her labor. Neither delivery complications nor any intramuscular injections were noted on her chart. The patient denied any local pain or trauma prior to her last hospitalization. Bacteria may be intro- duced to the joint through local invasion (through ruptured skin – lumbar epidural analgesia) or hematogeneousseedingduringtheperi-procedure period. There was no clue to support the poss- ibilityofhematogenicseeding,suchasfever,chills, systemic inflammatory response syndrome (SIRS) or sepsis, which would be expected to be present if the mechanism was hematogenic. Although bacterial sacroiliitis following lumbar epidural analgesia has not been previously reported in the literature, the proximity and timing, as well as DISCUSSION Bacterial sacroiliitis is a rare infection1–12, and the diagnosis is frequently missed unless the physician is familiar with the disease. A delay in the diagnosis may be associated with marked toxemia, and may necessitate surgical drainage of the septic joint. It may rarely even lead to death. The patient’s diagnosis was based on the following criteria: first, clinical symptoms of acute bacterial infection (severe continuous pain exacerbated by weight- bearing or any attempt to move the sacroiliac joint, high ESR, and leukocytosis with a left shift); secondly, bone and gallium scintigraphy demonstrating intense focal uptake in the right sacroiliac joint; and thirdly, an excellent clinical response to antibiotic therapy. In patients with bacterial sacroiliitis, Staphylo- coccus aureus and Streptococcus pneumoniae are the most frequently isolated organisms1,6,8, while Pseudomonas aeruginosa is commonly encountered in intravenous drug cultures are positive in only one-third to two- thirds of these patients2,5,8,10. Plain roentgeno- gramsandCTscansofthepelvisareusuallynormal at presentation1,4,8, as was the case in this patient. The earliest changes on the plain films occur 2 weeks after the onset of symptoms, and consist of blurring and erosions of the margins of the sacroiliacjoint,withwideningofthejointspace1,5. Scintigraphy is more sensitive for detecting early bacterial sacroiliitis4,6,10,13, and can demon- strateabnormalitiesinthejointsasearlyas2–6days into the illness4,8. The Tc-99m MDP bone scintigraphy and Ga-67 scintigraphy findings in abusers4,8,10,11,13. Blood INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY • 107 39 Z:\Customer\PARTHEN\IDOG\A4577 - IDOG Vol 11 No 2 - June 2003.vp 09 July 2003 14:29:42

  4. Color profile: Disabled Composite Default screen Bacterial sacroiliitis Edelstein and Edoute the absence of any other known risk factor, all suggest the possibility of lumbar epidural analgesia as a portal of entry. We consider it very important to report this finding, since it is clear that bacterial sacroiliitis should be considered as a possible serious complication of this procedure. Further reports are needed to establish the connection between this proposed causative pathogenesis of lumbar epidural analgesia sacroiliitis. and bacterial REFERENCES 1. Delbarre F, Rondier J, Delrieu F, et al. Pyogenic infection of the sacroiliac joint. Report of thirteen cases. J Bone Joint Surg Am 1975;57:819–25 2. Coy JT III, Wolf CR, Brower TD, et al. Pyogenic arthritis of the sacroiliac follow-up. J Bone Joint Surg Am 1976;58:845–9 3. Dunn EJ, Bryan DM, Nugent JT, et al. Pyogenic infections of the sacroiliac joint. Clin Orthop 1976;118:113–17 4. Gordon G, Kabins SA. Pyogenic sacroiliitis. Am J Med 1980;69:50–6 5. Longoria RR, Carpenter JL. Anaerobic pyogenic sacroiliitis. South Med J 1983;76:649–51 6. Oka M, Mottonen J Rheumatol 1983;10:475–8 7. Jajic I, Furst Z, Kraij K, et al. Septic sacroiliitis. An analysis of 14 patients. Acta Orthop Scand 1983;54:210–11 8. Kerr R. Pyogenic sacroiliitis. Orthopedics 1985; 8:1028–34 9. Shanahan MDG, Ackroyd CE. Pyogenic infection of the sacroiliac joint. A report of 11 cases. J Bone Joint Surg Br 1985;67:605–8 10. Shapiro SK, See CE. Pyogenic sacroiliitis. Minn Med 1986;69:201–4 11. Guyot DR, Manoli A II, Kling GA. Pyogenic sacroiliitis in i.v. drug abusers. Am J Roentgenol 1987;149:1209–11 12. Vyskocil JJ, McIlroy MA, Brennan TA, et al. Pyogenic infection Case reports and review of the literature. Medicine (Baltimore) 1991;70:188–97 13. Abbott GT, Carty H. Pyogenic sacroiliitis, the missed diagnosis? Br J Radiol 1993;66:120–2 14. Lurie S, Priscu V. Update on epidural analgesia during labor and delivery. Eur J Obstet Gynecol Reprod Biol 1993;49:147–53 15. Crawford JS. Some maternal complications of epidural analgesia for labour. Anaesthesia 1985; 40:1219–25 joint. Long-term of the sacroiliac joint. T. Septic sacroiliitis. RECEIVED 10/22/02; ACCEPTED 04/08/03 108 • INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 40 Z:\Customer\PARTHEN\IDOG\A4577 - IDOG Vol 11 No 2 - June 2003.vp 09 July 2003 14:29:42

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