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Case report: Epidural abscess in a parturient with pruritic urticarial papules and plaques of pregnancy (PUPPP)

[Présentation de cas : un abcès péridural chez une parturiente qui présente des papules et des plaques prurigineuses urticariennes de la grossesse (PPPUG)]

Kenneth C. Cummings, III, MD^* and James A. Dolak, MD PhD

^* From the Departments of Regional Practice Anesthesiology Hillcrest Hospital, Mayfield Heights; and
Obstetric Anesthesiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Address correspondence to: Dr. Kenneth C. Cummings III, Department of Anesthesiology, Hillcrest Hospital, 6780 Mayfield Road, Mayfield Heights, Ohio 44124, USA. Phone: 440-312-3022; Fax: 440-312-6963; E-mail: cummink2{at}ccf.org

Purpose: To describe the risk factors for epidural abscess (EA) formation following epidural analgesia in a parturient with pruritic urticarial papules and plaques of pregnancy (PUPPP).

Clinical Features: A 33 yr-old gravida 2 nulliparous patient at 36 weeks gestation presented with severe pre-eclampsia, and PUPPP (treated with prednisone). Magnesium prophylaxis was started and labour was induced. An epidural catheter was placed at the L_3-4 level using standard aseptic technique. Bupivacaine was incrementally injected to achieve a T₁₀ sensory level, and analgesia was maintained using a continuous infusion of 0.0625% bupivacaine with fentanyl. Nine days post-delivery, the patient developed back pain radiating to her right leg, but she was otherwise asymptomatic. She was afebrile; with a slightly tender, non-erythematous, non-draining, 1 cm nodule at the epidural catheter site. Motor and sensory examinations were normal at that time. However, the patient returned 24 hr later and further investigations revealed: WBC 17,800·mm^–3, platelets 486,000·mm^–3, erythrocyte sedimentation rate 50 mm·hr^–1, and C-reactive protein 8.8 mg·dL^–1. The magnetic resonance imaging demonstrated an EA at the L_3-4 level causing minimal cord compression. The patient underwent an emergency decompressive laminectomy. Cultures revealed methicillin-sensitive Staphylococcus aureus. Her pain improved, and she was discharged on the third postoperative day with a six-week course of iv ceftriaxone.

Conclusion: Causative organisms for EAs include coagulase-negative Staphylococci, S. aureus, and Gram-negative bacilli. Infection can occur either hematogenously or by direct contamination during catheter placement. Risk factors include immunocompromised states and PUPPP, as with the case of this patient.