British Journal o Anaesthesia 1994; 73 : 545-547 CASE REPORTS Meningitis after combined spinal-extradural anaesthesia in obstetrics S. A. HARDING, R. E. COLLIS AND B. M. MORGAN Summary We report two cases o f meningitis which developed after combined spinal-extradural procedures fo r obstetric analgesia. The first case was thoug ht to be caused by aseptic o r chemical meningitis an d the second was a case o f bacterial meningitis in a patient who also received an extradural blood patch. It is important that meningitis is considered as a differential diagnosis in patients who present with headache after spinal anaesthesia and that antibiotic therapy i s selected to cover unusual organisms. Br . J. Anaesth 1994; 7 : 545-547 ey words Anaesthesia, obstetric. Complications, meningitis. Case report CASE 1 A previously healthy 34-yr-old woman was admitted at term plus 9 days in early labour. Her first child had been delivered by emergency Caesarean section 3 yr previously. She requested extradural analgesia an d a combined spinal—extradural procedure w a s performed. Disposable pack an d needles were used, and the anaesthetist scrubbed an d wore a sterile gown and gloves. The skin wa s prepared with unstained chlorhexidine in alcohol from a receptacle on the extradural trolley, dried with a sterile towel and then infiltrated with 2 % lignocaine. The extradural space was located a t L2-3 with a standard Tuohy needle using loss of resistance to saline. A n 11. 9 cm, 27-gauge Whiteacre spinal needle w a s passed through the Tuohy needle and after free flow of clear fluid, 0.25 % bupivacaine 1 ml, fentanyl 2 5 ug and normal saline 0.5 m l (total volume 2 ml) were given into the subarachnoid space. The spinal needle w a s withdrawn and the extradural catheter inserted. Immediate analgesia w a s achieved with a sensory level to T8 bilaterally. The solution fo r extradural top-ups comprised 0.5 % bupivacaine 10 ml, fentanyl 100 ug and normal saline 38 ml in a 50-ml syringe. Three top-up doses of this solution were given during subsequent labour: 2 % lignocaine 10 ml was also given before a lift-out forceps delivery which w as performed f o r failure to progress in the second stage. A healthy baby girl was delivered 6.5 h after performing the combined spinal-extradural block. The patient was well the fol lowing m orning on the anaesthetic ward round, but at 13:00, 21 h after spinal injection, sh e developed a severe throbbing headache an d complained o f feeling faint an d with shortness o f breath. On examination she was apyrexial, heart rate was 68 beat min 1 , arterial pressure 90/60 mm Hg an ventilatory frequency 20 b.p.m ., but she was not cyanosed and had no neck stiffness. Four hours later s he w a s unable to pass urine an d required catheterization. At 18:00 the headache became more severe a n d she developed a n expressive an d receptive dysphasia an d tingling in the right side o f th e face an d right arm. We were concerned that she had suffered a subarachnoid haemorrhage o r a stroke and she was transferred to a neurological unit. After transfer sh e remained apyrexial bu t was then noted to have developed neck stiffness, a positive Kernig's sign and global aphasia. Neurological examination o f the cranial nerves w as normal an d reflexes o f the limbs were present an d symmetrical. One hour later she had a temperature of 38 °C. A CT scan was performed which showed no abnormality. Lumbar puncture demonstrated CSF pressure o f 12 cm H 2 O, WBC 725 x 10* litre 1 (74% polymorphs, 12 monocytes, 14 % lym- phocytes) an d RBC 27 x 10 * litre 1 . Increased pro- tein (1.82 g litre 1 ) an d normal glucose (2.3 mmol litre 1 ) concentrations were seen a n d blood glucose concentration wa s 5.0 mmol litre 1 . No organisms were seen o r subsequently cultured in CSF or blood. A ful l blood count showed a haemoglobin concentration at 10 g dl 1 , WB C 16.9 x 10 9 litre 1 , granulocytes 10. 8 x 10 9 litre 1 and platelets 196 x 10 9 litre 1 . A provisional diagnosis o f either bacterial or aseptic meningitis was made and she was given i.v. chloramphenicol, benzylpenicillin, ampicillin, flu- cloxacillin an d metronidazole. The antibiotics were chosen to cover both the common organisms known to cause meningitis and, in view of the history o f a recent breach o f the dura, more unusual pathogens. The following day, within 10 h o f commencing antibiotic treatm ent, the headache and neck stiffness had improved a n d aphasia ha d resolved. The anti- biotics were continued for 5 days and she w as discharged on day 5 having made a complete S. A. HARDING*, MB BCHIR, FRCA, R. E. CoLListi MB BS FRCA, B . M. MORGAN, MB CHB, FRCA, Department of Anaesthetics Institute of Obstetrics an d Gynaecology, Queen Charlotte s a nd Chelsea Hospital, Goldhawk Road, London W6 0XG. Accepted for publication: April 11 1994. Present address: * Royal Free Hospital, Pond Street, London NW3 2QG- t Royal London Hospital, Whitechapel, London El 2AD. Correspondence to S.A.H.