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Post Partum Diagnosis of Pott Disease
Abstract Number: F-49
Abstract Type: Case Report/Case Series
34 y.o. African female with IVF pregnancy was admitted at 23 wks gestation with suspected chronic abruption. Patient had a history of a positive skin tuberculin test but a negative chest Xray. Past surgical history was significant for a bilateral salpingectomy secondary to multiple tubo-ovarian abscesses. After one month of conservative management, at 27 weeks gestation, patient developed abrupt onset heavy vaginal bleeding. Fetal heart tracing showed minimal variability and occasional late decelerations. The decision was made to proceed with urgent cesarean delivery.
A CSE technique was performed utilizing a 17G epidural needle with a 26G spinal needle at the L3-L4 interspace. Standard sterile precautions were followed. Intrathecal injection of 1.4ml of 0.75% Bupivacaine, 15mcg of Fentanyl and 100mcg of PF Morphine provided a T4 anesthetic level 5 minutes after injection. A live female infant with Apgars of 6,7 was delivered and the procedure proceeded without any complications. On PPD3 patient complained of fevers. IV site was noted to be erythematous and indurated. Blood and Urine cultures were negative and patient was started on PO Cephalexin for probable cellulitis. After 48 hrs afebrile, patient was discharged. One week after discharge, patient was seen in clinic and reported fevers, once again. Antibiotics were continued to treat a probable endometritis.
On PPD#33, patient presents to the ER complaining of generalized malaise and high fevers. CT scan depicted an inflammatory reaction encompassing the L1-L2 vertebrae with adjacent psoas muscle abscess. Patient was admitted to the medicine service, PICC line placed and broad-spectrum antibiotics started for suspected osteomyelitis. The case was referred to the OB Anesthesia service as a possible complication from the neuraxial procedure performed at the time of delivery. After much deliberation, the patient agreed to a CT guided drainage of the Psoas muscle abscess but declined a vertebral bone biopsy. Analysis of the aspirate isolated genetic material of M. Tuberculosis. In light of these findings, the L1-L2 vertebral osteitis and diskitis were taught to result from chronic tuberculous disseminated disease and not, as initially assumed, the CSE. Patient was started on aggressive therapy with Izoniazid, Rifampin, Pyrizinamide and Ethambutol.
Pott disease has been highlighted in the past after placement of an epidural catheter in an obstetrical patient (1,2). Because of the temporal relation with the neuraxial procedure, these cases continue to be initially misdiagnosed as osteomyelitis arising from seeded skin bacteria such as Staph Aureus. When presented with a patient whose symptoms are insidious, especially in areas with large immigrant populations, providers should consider Pott Disease in their approach when managing possible infectious complications of neuraxial procedures.
1. Lee, B. Reg. Anesth. Pain Med. 27(2):220-4.2002
2. Morau, E. Anesthesiology. 103(2):445-6. 2005