2024 FSA Podium and Poster Abstracts
P060: SEPTIC MENINGITIS IN AN OBSTETRIC PATIENT
Tiffany Le, MD; Jennifer Cohn, MD; University of Miami/Jackson Health System
Introduction: The annual incidence for bacterial meningitis in the United States is 2.6-6 cases per 100,000 people and even rarer in the obstetric population. This can occur secondary to infection and/or inflammation resulting in the breakdown of the blood-brain barrier, increased microvascular permeability, diffuse cerebral edema and increased intracranial pressure. Symptoms include the classic triad (fever, nuchal rigidity, altered mental status), headache, rash, and seizures.
Case Presentation: A 29 year-old G3P2002 female at 37.0 weeks with no chronic past medical history presented to OB triage for LOF and contractions. Upon arrival, she was hemodynamically stable and afebrile with a mildly elevated WBC. She denied any recent illnesses or sick contacts. Issues in the peripartum period included absence of prenatal care and an admission at 13 weeks for suspected appendicitis s/p antibiotic treatment. She had a previous combined spinal-epidural without complications for a Caesarean section.
A CSE was performed with standard sterile technique by anesthesia personnel without complications. She then had an uncomplicated spontaneous vaginal delivery. One hour after delivery, the epidural catheter was removed with the tip intact.
The next day during morning lab collection, the phlebotomy team noted that the patient had altered mental status and complained of a headache and back/bilateral lower extremity pain. She was febrile, hypotensive, and tachycardic. Rapid response was activated. She was unable to follow commands and responsive only to noxious stimuli. She responded to a 1 liter normal saline bolus. Stroke alert was activated. Empiric antibiotic treatment was started for a concern for meningismus. Physical exam showed non-lateralizing findings. Neurologic imaging was unremarkable. She was transferred to the MICU to rule out meningitis. The next day, the patient recovered clinically.
Results: WBC count was elevated, blood cultures were positive for Streptococcus pneumoniae, and lumbar puncture was consistent with bacterial meningitis. CSF was positive for Streptococcus pneumoniae. She was transferred from the MICU to a medicine team floor. When blood cultures were negative, she was discharged with a midline in place for home IV antibiotic administration.
Anesthesia and nursing providers involved in the case were found to have used proper aseptic technique by infection control. They denied recent illnesses or sick contacts, and no other patients were ill. Therefore, nasal swabbing of personnel was not warranted. Anesthesia, nursing, and obstetric providers were followed for weeks after this event and found to follow proper sterile technique. The final diagnosis was community-acquired pneumonia.
Discussion: The leading cause of bacterial meningitis in adults is Streptococcus pneumoniae. Symptoms typically occur within 3-7 days after exposure to the insulting pathogen. In this patient, the rapid presentation of symptoms and the use of proper sterile technique make the neuraxial anesthesia provided less likely to be the cause of her disease. This case report highlights the importance of considering obstetric patients as those who are also susceptible to illnesses to the community as well as the urgency to recognize and manage bacterial meningitis if it should occur.