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Combined spinal epidural in a parturient with tinea versicolor
Abstract Number: SUN-01
Abstract Type: Case Report/Case Series
A 33-year-old parturient with history of tinea versicolor presented in active labor requesting epidural analgesia. Physical examination revealed a diffuse maculopapular rash on her back from the cervical to sacral regions (Figure 1). The patient ceased treatment of tinea versicolor in pregnancy. The theoretically small but unknown risk of introducing a subcutaneous yeast infection into the neuraxial space was discussed and informed consent was obtained.
Sterile skin preparation was performed for 30 seconds using 2% chlorhexidine gluconate/70% isopropyl alcohol. This preparation dried for three minutes and the sequence was repeated. The skin was infiltrated with 1% lidocaine. A combined spinal epidural technique was performed. The epidural space was identified using a 17G Touhy needle. A 27G spinal needle was used for intrathecal administration of bupivacaine and fentanyl. Labor analgesia utilized a programmed intermittent epidural bolus with patient controlled demand boluses. The catheter remained in situ for 13 hours. The patient delivered via cesarean delivery with an uneventful postoperative course.
Tinea versicolor is a benign superficial fungal infection caused by yeasts in the genus Malassezia and has an estimated prevalence of 2-8% in healthy adults. This infection presents with asymptomatic or mildly pruritic hypopigmented, hyperpigmented, or erythematous macules on the neck, torso and proximal upper extremities and is treated with topical or systemic antifungals. Two case reports of lumbar epidural analgesia in parturients with tinea versicolor have been reported; ours is the first case of combined spinal epidural analgesia. Despite the prevalence of tinea versicolor, systemic or CNS infection with Malassezia after neuraxial anesthesia has not been reported.
Rashes in the lumbar area should be accurately diagnosed prior to neuraxial placement. Microorganisms may be introduced into the neuraxial space via lapse in aseptic technique or colonization from skin. Despite placement of labor epidurals in bacteremic women and evidence of routine bacterial colonization of postoperative epidural catheters, epidural infections are rare, suggesting that the presence of microorganisms is necessary, but not sufficient, to cause neuraxial infections. The skin preparation, 2% chlorhexidine gluconate/70% isopropyl alcohol penetrates five layers of dermis and has antifungal properties. Local anesthetics have antimicrobial activity against both bacteria and fungi as well. The antifungal properties of both the skin preparation and local anesthetic solution as well as patient’s intrinsic immunologic defenses likely contribute to very low risk of neuraxial infections in parturients with tinea versicolor.
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