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Neuraxial anesthesia for a cesarean section in the setting of pityriasis rosea with skin lesions covering the lumbar spine
Abstract Number: T-09
Abstract Type: Case Report/Case Series
Pityriasis rosea (PR) is an acute exanthematous skin disease that begins with the appearance of a singular oval-shaped pink lesion followed by the eruption of numerous thin papules on the trunk and proximal extremities. A PubMed search for PR and neuraxial anesthesia yielded no results. We describe our clinical reasoning and management of a parturient with PR skin lesions covering her lumbar spine.
A 35 year-old (P 3-0-0-2) parturient at 39 and 2/7 weeks gestational age with a history of two prior cesarean sections presented with painful contractions and a two-week diagnosis of PR. Physical exam revealed numerous scattered, scaly, lightly erythematous thin papules distributed along skin relaxation lines over the abdomen, thorax, and proximal extremities. The patient was asymptomatic other than pruritus. Significantly, the entire lumbar spine was covered with lesions necessitating that any attempt at neuraxial anesthesia would require that needle puncture go through a papule. Despite determining that the patient was not in active labor, the obstetric team offered her an elective repeat cesarean section.
After consulting with the infectious disease team, it was determined that epidural placement should be safe, even if the needle had to transverse infected skin. Out of theoretical concern for seeding the cerebral spinal fluid, an epidural was chosen over a spinal anesthetic. A healthy baby was delivered in the operating room, the patient’s postoperative course was uneventful, and six weeks later her rash resolved.
There is now strong evidence that PR likely represents reactivation of human herpes virus 7 (HHV7), and to a lesser extent human herpes virus 6 (HHV6). Broccolo et al.  isolated HHV6/7 DNA from the plasma of patients with PR (DNA not found in healthy patients or patients with inflammatory skin disease) and found HHV7 DNA from skin specimens in 10/12 PR subjects versus 0/12 control subjects. Additionally, valacyclovir has been shown effective in decreasing the duration of PR.
HHV6/7 are beta-herpes viruses (unlike alpha-herpes viruses such as herpes simplex or herpes zoster which infect keratinocytes) which target CD4+ T-cells in the blood and are consequently found in very low concentrations in the skin. For this reason, while it may not be prudent to insert a needle through infected herpes simplex or herpes zoster, placing an epidural through infected PR skin likely poses no great risk.
1. Broccolo F, Drago F, Careddu A, et al. Additional evidence that pityrasis rosea is associated with reactivation of human herpesvirus-6 and -7. J Invest Dermatol. 2005; 124: 1234-40.
2. Katsafanas GC, Schirmer EC, Wyatt LS et al. In vitro activation of human herpesviruses 6 and 7 from latency. Proc Natl Acad Sci USA. 1996; 93: 9788-92.