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[caligas]

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55 yo female with severe positional headache 3 days post dural puncture to r/o fungal meningitis from a contaminated ESI. Cultures negative so far, one day of conservative treatment has failed. Flu like symptoms have resolved but severe headache persists.

Blood patch?

 

[Gern Blansten]

Yep, that one would cause me to be a bit worried. Was the LP clear of any infection?

 

[pgg]

Yep, that one would cause me to be a bit worried. Was the LP clear of any infection?

If they're looking to culture fungus, that might not be 100% "clear" for quite some time.



Is the headache positional? What "conservative" treatment has been tried? You can do a lot for a PDPH short of an EBP, but beyond the usual rest/fluids/caffeine.



edit - reading is fundamental 🙂

 

[Idiopathic]

nope. continue conservative care.

 

[Planktonmd]

Conservative therapy here too.
Too early to actually R/O positive fungal culture and I don't want to become part of the problem.
No one ever dies PDPH.

 

[pgg]

Do we know if this patient even got an ESI with steroid from a recalled lot?

I'd hate to blow off a patient who had an indication for an EBP because some ER-consulted-neurologist who was only told "I got an ESI" shotgunned a fungal culture on his LP.

If there's any doubt, and rest/fluid/caffeine conservative line has failed, and you don't want to blood patch her, and you don't think the headache is a symptom of something else that'll kill her, you could try Maxalt or Remeron or cosyntropin.


Of course, if she really does have a fungal meningitis cooking away, "conservative therapy for a PDPH" is the wrong answer too. She needs a diagnosis. Why'd she get the LP in the first place? Did she have a headache prior to the LP? Or just the flu-like symptoms in the aftermath of a maybe-contaminated ESI?

 

[periopdoc]

Good case.

I ain't going anywhere near her with a needle until it is documented that her ESI was not performed with potentially tainted steroid.

Perfect situation/ excuse for cosyntropin etc.

-pod

 

[BLADEMDA]

Good case.

I ain't going anywhere near her with a needle until it is documented that her ESI was not performed with potentially tainted steroid.

Perfect situation/ excuse for cosyntropin etc.

-pod

Agree. Do no harm first.

 

[Surfer]

wait a second here... why are you all so scared to do a blood patch on somebody who might have meningitis? You're scared that you might put sterile (non-infected) blood into an already infected space?? who cares?? please inform me what you could possibly harm by doing this? If they have meningitis, they already have it!! So doing the blood patch can't possibly make it worse. in fact, perhaps you are preventing the spread of infection into the epidural space causing an epidural abscess. you can't possibly harm them by putting sterile blood in there!

why wouldn't you do the blood patch? most likely they don't have it, and the blood patch makes them happy and cures their headache.

 

[urge]

I wouldn't do the blood patch. I dont' like doing them for regular pts. The concept doesn't sound good to me. I wouldn't get one done on me.

This one with the possibility of being infected makes me think twice. I wonder if the old blood will make treating any possible infection harder.

 

[pgg]

wait a second here... why are you all so scared to do a blood patch on somebody who might have meningitis? You're scared that you might put sterile (non-infected) blood into an already infected space?? who cares?? please inform me what you could possibly harm by doing this? If they have meningitis, they already have it!! So doing the blood patch can't possibly make it worse. in fact, perhaps you are preventing the spread of infection into the epidural space causing an epidural abscess. you can't possibly harm them by putting sterile blood in there!

why wouldn't you do the blood patch? most likely they don't have it, and the blood patch makes them happy and cures their headache.

It's less a matter of doing no harm to the patient, more a matter of doing no harm to one's malpractice carrier. Getting personally involved with an elective procedure around the spine of a person who has meningitis from some manner of someone else's negligence is just dumb.

Especially since there are some non-invasive options that probably haven't been tried yet.

I doubt an EBP is going to harm a person who already has meningitis, but I wouldn't be interested in having that discussion with a jury.

 

[dhb]

Blood patch with white blood cells: two birds w one stone 👍

 

[Idiopathic]

1. Its an elective procedure, no medical emergency
2. Noninvasive management strategies exist
3. The fewer providers that put needles in the backs of chronic pain patients, the better

 

[Arch Guillotti]

I wouldn't do a blood patch either.

wait a second here... why are you all so scared to do a blood patch on somebody who might have meningitis? You're scared that you might put sterile (non-infected) blood into an already infected space?? who cares?? please inform me what you could possibly harm by doing this? If they have meningitis, they already have it!! So doing the blood patch can't possibly make it worse. in fact, perhaps you are preventing the spread of infection into the epidural space causing an epidural abscess. you can't possibly harm them by putting sterile blood in there!

why wouldn't you do the blood patch? most likely they don't have it, and the blood patch makes them happy and cures their headache.

 

[TrustMe]

If she does indeed want a blood patch, why isn't she sent to the person that did the ESI, and why isn't he/she the one that did the LP for diagnosis (as he/she likely would not have used the 20 or 22 ga needle for the LP, causing the PDPH in the first place). It doesn't seem like the person that potentially caused the problem (likely unknowingly intitially) is involved in this patients care, when, in my opinion, they should be the first person involved in her care.

 

[Surfer]

i'm amazed at how many of you are complete p#$#ies. she wants a blood patch. discuss with her the risks/benefits, then for the LOVE, give the lady a freaking blood patch!!

don't refer it to the ER doc that tapped her... he/she has never done a blood patch before.

don't stall with "conservative management" it's just stalling. She's had a headache for days now and is willing to accept the risks to get rid of it. By the way, many women who get spinal headaches after child birth say the headache was worse than the labor pains. These headaches HURT.

conservative management usually don't work... sure, with time it will go away... eventually. But she wants the BLOOD Patch. so give her a blood patch!

nobody here has given a single legitimate reason not to give the patient what they want, a blood patch. you have the training and the moral obligation to provide the services at your hospital. so do it. quit being such a candyass worried about whether or not she gets a sore back from your needle (do we worry so much about epidurals??)

geeze....

 

[urge]

Isn't it funny that the junior most person is the only one willing to do the blood patch?

 

[pgg]

i'm amazed at how many of you are complete p#$#ies. she wants a blood patch. discuss with her the risks/benefits, then for the LOVE, give the lady a freaking blood patch!!

😀

don't refer it to the ER doc that tapped her... he/she has never done a blood patch before.

don't stall with "conservative management" it's just stalling.

Conservative management usually means fluids, rest, caffeine, OTC analgesics.

However, there's another tier of conservative management that isn't fairly called stalling. Maxalt, Remeron, cosyntropin all work (in some people) and don't involve another needle stick.

I've begun to routinely use Maxalt in patients with PDPHs, especially the ones who show up with a bit of color to the story or a headache that seems a little atypical.

I think those are excellent options for this patient. Nothing in the OP suggests the patient arrived demanding an EBP. We're allowed to be doctors and assess the patient and pick (recommend) a treatment we feel best balances risks and benefits.

She's had a headache for days now and is willing to accept the risks to get rid of it. By the way, many women who get spinal headaches after child birth say the headache was worse than the labor pains. These headaches HURT.

conservative management usually don't work... sure, with time it will go away... eventually. But she wants the BLOOD Patch. so give her a blood patch!

nobody here has given a single legitimate reason not to give the patient what they want, a blood patch. you have the training and the moral obligation to provide the services at your hospital. so do it. quit being such a candyass worried about whether or not she gets a sore back from your needle (do we worry so much about epidurals??)

geeze....

As I mentioned in my first two posts in this thread, I wouldn't reflexively refuse to do the EBP.

I am a little curious why I am being asked to do an EBP when she already has a relationship with ESI-dude. I wouldn't expect 20g-cutting-needle-neurology-dude to clean up his PDPH mess, but before I agree to get involved here, I'd just like more information and some time to contemplate the ifs.



I think you're probably right, the actual risk of an EBP is close to zero, beyond the usual EBP risks (namely, does she have a life-threatening headache NOT caused by a dural puncture, and the EBP further delays treatment of the real cause).

But sometimes the risk of getting sued is a good reason to not get involved more than you have to. You can call this being a p#$#y, but look at what we've got here: A patient who may have been harmed by a contaminated drug injected into her spine. If she's growing fungus in her spine and brain because of it, you KNOW she's going to be in a litigous mood. You KNOW that when patients sue one doctor, they usually get talked into suing them all. You KNOW that somewhere there's an expert witness who'll testify that doing an EBP in a fungal-meningitis patient is outside the standard of care and that her new chronic back pain is a result of you injecting a nice fungal culture medium into an infected space.

I do kind of respect your willingness to say damn the lawyers, full speed ahead, I'm going to do what I think is best for the patient.

But if she indeed got an ESI from a contaminated batch, I'm not putting a needle in her back.

 

[Jay K]

No.

 

[periopdoc]

Well for the cowboy 🙄, perhaps a little reading on the contraindications and success rates of epidural blood patch are in order.

The major contraindications are patient refusal, coagulopathy, and localized or systemic infection. Blood is a great growth medium, especially if it is just sitting in an extravascular space. You are going to be in for a hell of a time if the patient develops and epidural abscess because you decided to inject a culture medium into her infected spine.

Success rate of epidural blood patches is about 80-85%... about the same as conservative treatment and pharmacologic treatment. There are other options and no one was ever permanently harmed from a PDPH or from lack of a blood patch.

The doc that we are saying should be managing this is not the ER doc, it is the guy who did the ESI in the first place. If he can do an ESI, he can manage any complications and do a blood patch. No reason for me to get involved.

Now you said discuss the risks and benefits to her. Care to enlighten us on the risks and benefits of performing a epidural blood patch in a patient who is being ruled out for fungal meningitis?

Once that ball is rolling, there is no way of stopping it. It is kind of like a rule out MI in preop... Whether the rule out is appropriate, once your partner has initiated the rule out, you have to wait for the completion of the rule out before proceeding to the OR, otherwise you open yourself up to a whole host of medical-legal issues even if something happens that is true, true and unrelated.

- pod

 

[IlDestriero]

Isn't it funny that the junior most person is the only one willing to do the blood patch?

Hahaha. I wouldn't touch her with a 10 foot pole. Non invasive treatment only.

 

[Oggg]

If the LP results were stone cold normal, she's got not meningitis symptoms, she's got a perfect positional occipital headache, and the orthopod who did her ESI already put her on conservative treatment, and she's insistent on an EBP so she can go home and take care of her three toddlers... now what do you do?

I agree with not doing EBP if the LP is unclear, and if conservative mgmt hasn't been tried yet. In the perfect scenario above, can u make a case for safely (medically and legally) doing an EBP? Of course I would consent her thoroughly and try to scare her with the outside risks of infection, bleeding, delayed recognition of fungal meningitis, and possible wet tap. I'd try to convince her that PDPH often resolves on its own
EBP includes a risk of wet tap

 

[proman]

If the LP results were stone cold normal, she's got not meningitis symptoms, she's got a perfect positional occipital headache, and the orthopod who did her ESI already put her on conservative treatment, and she's insistent on an EBP so she can go home and take care of her three toddlers... now what do you do?

No way. Some patients are presenting weeks after their injections. These fungal infections can be very slow growing and it's just not worth the risk to the patient. Non-invasive treatment only.

 

[Surfer]

No way. Some patients are presenting weeks after their injections. These fungal infections can be very slow growing and it's just not worth the risk to the patient. Non-invasive treatment only.

what "risk to the patient?" can you show me a single case of a documented lumbar epidural abscess that came from giving somebody an EBP who already had meningitis?

I looked and couldn't find one... maybe somebody else can? in fact, we do them all the time on people who get spinal taps and have preliminarily negative taps. ALL THE TIME. and we do them on people post meningitis too. There's no risk.

If you're really concerned that she MIGHT have a fungal infection, then put her on fluconazole. I really don't think plugging that hole with sterile blood is going to give it a new "culture medium" as some have claimed. the literature just doesn't support that idea. cure her headache and move on...

 

[dhb]

There's no risk.

This is never true.
Although you are right that risk is probably very low, no one is going to risk a PITA lawsuit for a condition created by someone else and that can be managed by other means.
Risk / rewards just isn't there, the truth is if any complication arises (not only infectious) you'll be thrown under the bus, especially by the person that created the situation.

 

[92122]

"Isn't it funny that the junior most person is the only one willing to do the blood patch?"

Considering what I've seen of those going through with mounds of paperwork, depositions and the like, it's hard to imagine wanting to get involved in this situation.

Mistakes that one makes can change one's career outlook quite dramatically.

Slow it down a bit, surfer. Your career hasn't even begun...

 

[pgg]

what "risk to the patient?"

Again, it's not risk to the patient but risk to YOU.

This patient is going to sue multiple entities over the ESI. You know she will. It may suck that we have to practice defensively, but it's the truth. Getting your name in that chart as a spine needle driver can only end badly.

Are the ER guys "p#$#ies" because they order too many CTs?

 

[proman]

what "risk to the patient?" can you show me a single case of a documented lumbar epidural abscess that came from giving somebody an EBP who already had meningitis?

I looked and couldn't find one... maybe somebody else can? in fact, we do them all the time on people who get spinal taps and have preliminarily negative taps. ALL THE TIME. and we do them on people post meningitis too. There's no risk.

If you're really concerned that she MIGHT have a fungal infection, then put her on fluconazole. I really don't think plugging that hole with sterile blood is going to give it a new "culture medium" as some have claimed. the literature just doesn't support that idea. cure her headache and move on...

Absence of evidence is not evidence of absence. I can't get this journal but here's one paper that may shed light. BTW treatment for fungal meningitis in the non-AIDS non-immunocompromised patient is amphotericin or a triazole antifungal like voriconazole. Are you going to admit the patient on your service to give amphotericin?

Int J Obstet Anesth. 2005 Jul;14(3):246-51.
A subdural abscess and infected blood patch complicating regional analgesia for labour.
Collis RE, Harries SE.
Source

Department of Anaesthetics, University Hospital of Wales, Cardiff, UK.
Abstract

We report two very unusual cases of infection complicating labour analgesia. The first case was a sub-dural abscess presenting with deep-seated backache seven days after combined spinal-epidural analgesia for labour. The second was a painful lumbar swelling and septicaemia that presented three days after a blood patch for a post dural puncture headache. Because of their complicated and unusual presentation, the diagnosis and management of both were initially delayed.

PMID:
15935637
[PubMed - indexed for MEDLINE]

 

[periopdoc]

what "risk to the patient?" can you show me a single case of a documented lumbar epidural abscess that came from giving somebody an EBP who already had meningitis?

Can you give us a single example of someone (other than yourself) dumb enough to perform an EBP in a patient who already had meningitis?

I really don't think plugging that hole with sterile blood is going to give it a new "culture medium" as some have claimed.

If you are going to call me out, call me out. I called it the perfect culture medium and it is.

Let me ask you this. What are the contraindications to epidural blood patch?

- pod

 

[IlDestriero]

Interestingly, the news reported 19 new confirmed cases of meningitis over several states yesterday.

 

[Surfer]

Can you give us a single example of someone (other than yourself) dumb enough to perform an EBP in a patient who already had meningitis?



If you are going to call me out, call me out. I called it the perfect culture medium and it is.

Let me ask you this. What are the contraindications to epidural blood patch?

- pod

She doesn't have meningitis. Her tap is clean 3 days out!! Is she going to develop it? I'm not an id expert so I can't say for sure but I'm going to ask what the chance of her having it is with an already clean tap. This scene is being played out all over America. Most anesthesiologists are asking if the tap was clean, if it was, they give the blood patch. There are always a million maybe scenarios, but with a clean tap they're fixing the hole and the patient is happy.

 

[pgg]

She doesn't have meningitis. Her tap is clean 3days out!! Is she going to develop it? I'm not an id six so I can't say for sure but I'm going to ask what the chance of her having it is with an already clean tap. This scene is being played out all over America. Most anesthesiologists are asking if the task was clean, if it was, they give the blood patch. There are always a million maybe scenarios, but with a clean tap they're fixing the hole and the patient is happy.

The difference this time is a known (?) fungal exposure. A 3-day negative fungal culture is not negative. Someone was specifically worried enough about fungus to tap her and culture, for fungus.

This is not your average neurologist-inflicted PDPH after a negative bacterial meningitis workup.

 

[periopdoc]

SThis scene is being played out all over America. Most anesthesiologists are asking if the task was clean, if it was, they give the blood patch.

In an unscientific sample of docs who, as a group. lean toward the cowboy side of anesthesia we have 12 attending level anesthesiologists saying no way, one attending level who is waffling a bit but saying only if all other options have been explored and even then only with caution, and one resident level anesthesiologist saying "damn the torpedoes, full speed ahead."

Would you care to rethink that statement doctor?

- pod

 

[proman]

I called it the perfect culture medium and it is.

- pod

I call it chocolate agar.

 

[Surfer]

I'm not a resident, haven't been for a while now. Just never got around to changing my status because i don't care.

i think you guys are perpetuating bad dogma. i have several querries out to ID specialists and pathologists to see about that 3 day clean tap. See, in real life, this is what i would do, I'd check with ID and if they say "she's clean" I'd do it without a worry.

But you guys are just perpetuating this bad dogma that "I wouldn't touch her with a ten foot pole" because you're afraid of getting sued. The only people getting sued here are going to be the drug manufacturer. Remember, medical malpractice requires several factors:

1) a duty - the doc doing the ESI had a duty. As soon as you were consulted for the blood patch you also received a duty.

2) deviation from the standard of care - the ESI doc did not deviate in any way, shape or form from the "standard of care." There was no way he could have known he was dealing with a bad batch of steroid. Sure, "standard of care" is usually debated, but in this case the ESI doc will get summary judgment by a judge saying he did not deviate from the standard of care. As soon as you are consulted for the EBP, you also have to follow the standard of care. In my opinion, with a clean tap the standard of care is to give the blood patch. Debatable, sure, you have no evidence that she's infected, and she certainly doesn't have meningitis at this point.

3) Damages - there have to be damages. No meningitis? No damages. Emotional suffering from worrying about it? That would be very hard to prove, but not out of the question considering today's legal climate. But, again, the ESI doc didn't deviate from the standard of care, so he's not liable for the damages.

4) Causation - Damages have to be CAUSED by the deviation in standard of care. If somebody gets meningitis from the steroid, the damages were not caused by a deviation in standard of care (assuming sterile technique, etc). So not liable. In the case of a blood patch, if you somehow in the 1:1,000,000 chance get an epidural abscess (from the aspergillus) after giving somebody with a CLEAN tap an EBP then perhaps you might have to pony up if you didn't explain the risks/benefits and document it all. If you did explain the risks/concerns, then you didn't deviate from the standard of care. Put another way, you have all the evidence saying she's "clean" and no evidence saying she has aspergillus in her csf. In the case where she still wants an EBP, and understands that there's some outside chance you might seed the lumbar space (its already leaking there) then she might sue. But that's a risk you run every single time you perform an EBP.

I'll post data when I get it about how long it takes aspergillus to show up on tap, or whether a blood patch could grow that out in the epidural space. In the meantime, don't accept this nonsense dogma of "conservative therapy" so you don't sued. IN fact, I've seen plenty of lawsuits for "failure to perform."

And yes, I've sat on the legal stand in a medical malpractice case (not my own). How many of you have?

 

[Surfer]

In an unscientific sample of docs who, as a group. lean toward the cowboy side of anesthesia we have 12 attending level anesthesiologists saying no way, one attending level who is waffling a bit but saying only if all other options have been explored and even then only with caution, and one resident level anesthesiologist saying "damn the torpedoes, full speed ahead."

Would you care to rethink that statement doctor?

- pod

i'm a board certified anesthesiologist, just like you.

here's something you should know about apergillus: Culture: Clinical specimens should be inoculated onto primary isolation media, like Sabouraud's dextrose agar. Colonies are fast growing and may be white, yellow, yellow-brown, brown to black or green in colour."

I just heard back from ID and path... 3 days is clean is clean is clean. No aspergillus in that medium if it hasn' grown out in 3 days.

Care to change your answer doctor???

 

[proman]

i'm a board certified anesthesiologist, just like you.

here's something you should know about apergillus: Culture: Clinical specimens should be inoculated onto primary isolation media, like Sabouraud's dextrose agar. Colonies are fast growing and may be white, yellow, yellow-brown, brown to black or green in colour."

I just heard back from ID and path... 3 days is clean is clean is clean. No aspergillus in that medium if it hasn' grown out in 3 days.

Care to change your answer doctor???

We've had patients present 1 month after injection. We've had 1 patient die. Aspergillus isn't the only fungus, exserohilum (WTF?) has caused at least 12 cases. This is a rapidly developing outbreak, and all the facts aren't known. You're way too cavalier on this. First, do no harm.

 

[Gern Blansten]

what "risk to the patient?" can you show me a single case of a documented lumbar epidural abscess that came from giving somebody an EBP who already had meningitis?

I looked and couldn't find one... maybe somebody else can? in fact, we do them all the time on people who get spinal taps and have preliminarily negative taps. ALL THE TIME. and we do them on people post meningitis too. There's no risk.

If you're really concerned that she MIGHT have a fungal infection, then put her on fluconazole. I really don't think plugging that hole with sterile blood is going to give it a new "culture medium" as some have claimed. the literature just doesn't support that idea. cure her headache and move on...

I think this is being confused with run of the mill non-iatrogenic meningitis. In that case, with a clean LP, I would go ahead. In this case, I would not. As mentioned by many others, there are many good reasons to not instrument her neuraxial space.
You mentioned that if you think she does have the iatrogenic fungal infection, you would go ahead and just administer fluconazole. Is that what you are saying? I think that would be a terrible choice. I suspect that intravenous anti fungals would need to be used to get the CSF concentration needed. I would not do a blood patch but would treat with other agents as mentioned.

 

[pgg]

As soon as you were consulted for the blood patch you also received a duty.

One last nit to pick -

Not consulted to do a blood patch.

Consulted to evaluate a possible PDPH and treat as appropriate. 😉

I've sat on the legal stand in a medical malpractice case (not my own). How many of you have?

I've been deposed a couple times and did something akin to expert witness advice to defense attorneys for a case vs the US Govt a year or two back.

None of it's fun. It's all time I'll never get back.

I've never been cross-examined by some Perry Mason wannabe - nor do I want to be. I wouldn't get that time back, either.


I won't dispute that the 4 elements of malpractice you listed are correct - they are. But while they may get you off (after some lawyerly effort), they won't keep you out of court.

I practice in hands-down, the most favorable malpractice environment in the United States. I generally DON'T let dogma-fueled lawsuit fears stop me from doing what I think is the right thing, in part because I have a literal army of salaried lawyers behind me whose sole purpose in life is to nitpick to death and fight tooth and nail EVERY claim (even the slam-dunk valid ones). Even so, it's not worth getting involved in cases like this. It's just not.

When I moonlight, I am much more defensive because I don't have that horde of lawyers behind me. Call me a wuss if you will.


To clarify my wafflin' 🙂 ... in threads like these, I hate to declare an absolute course of action in the face of partial information, but it's not likely that I'd do an EBP here.

If I could confirm, or was unsure, that this patient actually got an ESI from a contaminated batch of steroid, I wouldn't EBP her.

If it turns out that this LP headache workup and fungal culture was just a CYA move from a neurologist who heard ESI and went high & right on it, and I could confirm that her ESI steroid wasn't from a recalled lot, I'd EBP her ... maybe, after some Maxalt. (But this implies I could reach the guy who did the ESI, and in that case, the whole thing might get turfed back to him and it's not my problem.)

 

[Orin]

Blood patch with white blood cells: two birds w one stone 👍

I call it chocolate agar.

I called it the perfect culture medium and it is.

This has never made sense to me 😕 The idea that whole blood is a great culture media seems like something that just gets passed on in medical lore, and I haven't been able to find a source for it.

Blood agar is not = to whole blood. The blood for culture is defibrinated or very diluted, so it doesn't clot or prevent bacterial growth.

Obviously blood can grow stuff and it may help things grow better in certain situations, but it's not like we're in raging sepsis every time a few bacteria/fungi get in our bloodstream.

</rant>
Great thread though.

 

[periopdoc]

This has never made sense to me 😕 The idea that whole blood is a great culture media seems like something that just gets passed on in medical lore, and I haven't been able to find a source for it..

Look into transfusion medicine and the difficulty encountered with pathogenic contamination of blood components.

The body is quite amazing at removing bacteria from intravascular blood. Once blood pools outside of the bloodstream, it can no longer be cleared in the same manner. This is one of the major reasons surgeons place drains in wounds.

- pod

 

[periopdoc]

i'm a board certified anesthesiologist, just like you.

Apologies.

here's something you should know about apergillus...
I just heard back from ID and path... 3 days is clean is clean is clean. No aspergillus in that medium if it hasn' grown out in 3 days.

Care to change your answer doctor???

Nope, my answer remains the same. The FDA still has not released the identity of the fungal contaminant seen in the sealed methylpred vials. They observed the contaminant microscopically prior to their announcement on 10/5/12 and as of their most recent update of 10/15/12 they have not released the identity of the organism responsible for the contamination. Could it be because it is slow growing or otherwise difficult to culture/ identify? I don't know, but I feel it is prudent to consider it so until we know otherwise for certain (especially given how delayed the presentations of fungal meningitis have been.)



The last word the FDA gave us on the issue of identity was in their 10/12 update

FDA, in partnership with CDC, is in the process of attempting to identify the exact species of fungus isolated from the sealed vials and whether the fungus is the same as one of the two fungal organisms found in patients.

You mentioned aspergillus, this is a probably a red herring, and it certainly is nothing to hang your hat on in regards to the causative organism of the meningitis cases.

The aspergillus infection was in a transplant recipient who received cardioplegia from NECC that could potentially have been contaminated. There are a lot of reasons for a transplant recipient to become infected with aspergillus. I would wait for definitive identification of the contaminate in the methylpred vials before I started taking any comfort in clean fungal cultures.

- pod

 

[urge]

This has never made sense to me 😕 The idea that whole blood is a great culture media seems like something that just gets passed on in medical lore, and I haven't been able to find a source for it.

Blood agar is not = to whole blood. The blood for culture is defibrinated or very diluted, so it doesn't clot or prevent bacterial growth.

Obviously blood can grow stuff and it may help things grow better in certain situations, but it's not like we're in raging sepsis every time a few bacteria/fungi get in our bloodstream.

</rant>
Great thread though.

Have your ever heard of a retroperitoneal hematoma? What do people die from when they get that (other than bleeding)?

 

[periopdoc]

But you guys are just perpetuating this bad dogma that "I wouldn't touch her with a ten foot pole" because you're afraid of getting sued.

Personally, my concern is not for getting sued. Once again I ask you, what are the contraindications to epidural blood patch?

- pod

 

[caligas]

Thanks for the excellent discussion. With input from our local I.D. folks we have decided not to patch these patients at our hospital.

 

[periopdoc]

Interesting. What input did the ID folks give?

-pod

 

[caligas]

Basically what has already been said: injecting a growth medium near the site of possible infection might be bad, negative cultures after a few days may not be sensitive, etc.

 

[periopdoc]

Been out hunting since last Friday and am catching up today. The FDA has released the identity of the fungus found in the vials as being Exserohilum rostratum but has cautioned that other organisms may yet be found.

There was a good, free article in NEJM on Friday with a rundown of what we know to date. Fungal Infections Associated with Contaminated Methylprednisolone Injections — Preliminary Report .

Germane to this discussion are the following quotes.

Even though the mold grows readily in the laboratory, cultures from cerebrospinal fluid may be negative,

Increasing back pain or pain that differs in quality from the chronic back pain for which a patient received an epidural injection may be the only symptom of an epidural abscess, diskitis, or vertebral osteomyelitis. Magnetic resonance imaging of the spine should be performed in such patients, since early symptoms of these compli-cations can be subtle, and localized infection may occur without meningitis.

Treatment of Patients with Normal Cerebrospinal Fluid

Should patients who have symptoms but are found to have fewer than 5 white cells per cubic millimeter in cerebrospinal fluid be treated? Without objective evidence of infection in the cerebrospinal fluid, treatment is not recommended. However, patients who have symptoms should be monitored closely, and if there is even subtle progression of symptoms, a repeat lumbar puncture should be performed immediately. If the number of white cells has increased, then empirical antifungal treatment should be initiated immediately.

So it seems that the experts that I have access to are still urging caution until the full scope of this issue is understood. If the patient could prove to me that she did not get an injection with a pharmaceutical manufactured (compounded) by NECC, I would be willing to do the blood patch. However, I fail to see why the person who did the injection should not be the one managing it at this point. I think that it is critical that the injecting physician be contacted so that he/ she can manage the long-term (from an anesthesia perspective) follow up that is necessary. If I had done the procedure, I would certainly want to be contacted about any possible complications.

- pod