Case Report ISSN 2639-846X

Anesthesia & Pain Research

Chemical Meningitis Following Spinal Analgesia with Levobupivacaine in

Labor and Delivery: A Case Report
Anamarija Predrijevac1, Alan Šustić2, Igor Antončić3, Siniša Dunatov3, Željko Župan2, Janja Kuharić2,
Boban Dangubić2 and Vlatka Sotošek Tokmadžić2*

Faculty of Medicine, University of Rijeka, Croatia, Brace

1

Branchetta 20, 51000 Rijeka, Croatia. Correspondence:

*

Vlatka Sotošek tokmadžić, MD, PhD, Department of Anaesthesia,

Department of Anaesthesia, Resuscitation and Intensive Care
2 Resuscitation and Intensive Care Medicine, Faculty of Medicine,
Medicine, Faculty of Medicine, University of Rijeka, Croatia, University of Rijeka, Brace Branchetta 20, 51000 Rijeka, Croatia,
Brace Branchetta 20, 51000 Rijeka, Croatia. Tel: +38551651182; E-mail: [email protected].

Department of Neurology, Faculty of Medicine, University of

3
Received: 14 October 2017; Accepted: 05 November 2017
Rijeka, Croatia, Brace Branchetta 20, 51000 Rijeka, Croatia.

Citation: Predrijevac A, Šustić A, Antončić I, et al. Chemical Meningitis Following Spinal Analgesia with Levobupivacaine in Labor and
Delivery: A Case Report. Anesth Pain Res. 2017; 1(1): 1-3.

ABSTRACT
Chemical meningitis is a very rare but potentially devastating complication of spinal anaesthesia and analgesia.
It can be provoked by intrathecal application of substances, such as local anaesthetics, or may occur as a result of
the anaesthesia technique used. We describe, until now published, a case of 20-year-old primipara who received
spinal analgesia with levobupivacaine for labor and delivery and developed generalized epileptic seizures and high
fever. Laboratory tests showed an increased white blood cell count, elevated neutrophil granulocytes, and elevated
C-reactive protein; the cerebrospinal fluid (CSF) analysis showed increased levels of proteins, lactate, leukocytes,
and erythrocytes. A brain computed tomography (CT) and CT angiography scan did not reveal any pathological
alteration. Microbiological analysis of CSF and blood cultures did not show any pathogen growth, and the patient
was treated with antibiotics and corticosteroids. The patient later fully recovered and was discharged from the
hospital.

Keywords literature until now unpublished, a case of chemical meningitis

Levobupivacaine, Meningitis, Spinal analgesia, Status epilepticus. following spinal analgesia with levobupivacaine.

Introduction Case Report

Spinal anaesthesia is one of the most reliable and versatile A 20-year-old primipara at 39 weeks of pregnancy received spinal
techniques available for providing anaesthesia and analgesia for analgesia for labor and delivery. The technique and possible
labor and delivery. Although it has been used since the 1800s, its complications of spinal analgesia were explained to her, and
frequency of use decreased due to complications and the invention she signed the informed consent form. The primipara was in a
of the epidural technique. It became popular again with the sitting position. An aseptic washing solution containing iodine
development of newer, beveled needles. Spinal anaesthesia has (Antiseptica, Pulheim, Germany) was applied, and the excess
many advantages, including extremely rapid onset of pain relief solution was removed. Spinal anaesthesia was performed at the L2-
and the ability to retain motor control, but it is not free of side to-L3 level using an atraumatic 26-gauge spinal needle (B Braun,
effects [1,2]. The most common side effects of spinal analgesia are Melsungen, Germany). When the spinal space was detected, 1.5
hypotension and post-dural puncture headache [3]. These effects mL of 0.5% levobupivacaine (Fressenius Kabi, Bad Homrung,
are usually mild, well tolerated, and transient [4]. More serious Germany) and 2.5 μg of sufentanil (Renaudin, Itxassou, France)
side effects, such as meningitis or seizures, are rare but potentially were applied intrathecally. Within five minutes, the patient felt pain
fatal. When meningitis, either chemical or bacterial, or epilepsy relief and in forty minutes, she delivered a healthy baby boy. The
occurs, they must be treated without delay. We describe, in English next day she began to complain of a headache, neck and shoulder
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pain, and neck stiffness. Pain in the frontal area of the head was blood cultures did not show any growth of pathogens, and 125 mg
more intense when she stood up. Analgesic therapy (diclofenac, methylprednisolone (Pfizer Manufacturing, Rijksweg, Belgium)
Voltaren, Pliva, Zagreb, Croatia) and hydration with crystalloid was administered intravenously. Electroencephalography (EEG)
fluids were prescribed to the patient, and she was advised to stay showed slow activity in the fronto-temporo-central area of the brain.
in bed. She felt well, did not have a headache or other symptoms, The patient was mechanically ventilated for the next 4 days. She
and was discharged from the hospital 2 days after the delivery. was hemodynamically stable, occasionally tachycardic, and sub-
febrile. Analgosedation was discontinued 6 days after admission
On the third day postpartum, while breast-feeding; she had two to the neurologic intensive care unit; the patient was weaned
generalized epileptic seizures at her home. Her husband called from the ventilator and extubated. She was alert, complained of
an emergency medical service that transported the patient to the a mild headache, and had neck stiffness. The remainder of her
emergency room at the Clinical Hospital Centre Rijeka, Rijeka, examination was unremarkable, without neurological deficits.
Croatia. During transportation, she had another generalized Brain magnetic resonance imaging (MRI, Avanto 1.5 T, Siemens,
seizure and urinated herself. On arrival at the emergency room, she Germany) showed postictal edematous changes (Figure 1). During
was conscious but disoriented. Neurological examination revealed the clinical course of her illness, the patient fully recovered and
neck stiffness. Inspection of the spinal puncture site did not reveal was discharged from the hospital. Oxcarbazepine (Trileptal,
any signs of infection. Laboratory tests showed an increased Novartis Farma, Naples, Italy) at a dose of 300 mg twice per day
white blood cell count, elevated neutrophil granulocytes, and was prescribed. Clinical examination of the patient three months
elevated C-reactive protein. Multi-sliced computed tomography after hospital discharge showed no neurological deficits, and the
(MSCT, Avanto 1.5 T, Siemens, Forcheim, Germany) and results of all laboratory tests were within normal ranges.
computed tomography (CT, Sensation 16, Siemens, Forcheim,
Germany) angiography of the brain were normal. The results of
the cerebrospinal fluid (CSF) analysis are shown in Table 1.

Results Normal range

Proteins (g/L) 2.79 0.17-0.37
Glucose (mmol/L) 3 2.49-4.44
Lactate (mmol/L) 3.3 1.1-2.2
Chloride (mmol/L) 122 111-126
Pandy Positive Negative
Leukocytes (x106/L) 38 <5
Erythrocytes (x10 /L)
6
477 0
Lymphocytes (%) 4 70-100
Neutrophils (%) 73 0
Monocytes (%) 23 0-30

The patient was then admitted to the neurological intensive care

unit, where she was treated with continuous infusion of 0.01 mg/
kg/h of tramadol (Stada, Bad Vilbel, Germany) and 50 μg/kg/h of
midazolam (Roche, Basel, Switzerland).

Blood cultures were taken and intravenous triple antimicrobial Discussion

therapy with 2 g meropenem (Sandoz International GmbH, Neurologic complications after spinal anaesthesia in obstetric
Holzkirchen Germany) three times per day, 1 g vancomycin patients are fortunately rare, and often occur as a complication of
(Xellia Pharmaceuticals ApS, Copenhagen, Denmark) three times neuraxial block. They can be classified into three groups: 1) those
per day, and 750 mg acyclovir (GlaxoSmith Kline, Bredford, related directly to anaesthesia, 2) those unrelated to anaesthesia,
UK) three times per day was started. The next day the patient and 3) those in which anaesthesia is incidental but possibly a
was somnolent, respiratory and hemodynamically stable, and contributing factor [5].
febrile up to 38.7°C. Two days after admission to the neurological
intensive care unit, she had a generalized convulsive seizure Chemical meningitis after spinal anaesthesia was previously
followed by altered consciousness, and during the night, she considered to be related to antiseptics and cleansing agents
developed status epilepticus. She was febrile up to 39°C, and adhering to syringes and needles used for this technique with
was then endotracheally intubated and mechanically ventilated. incidence reported 0.2% [6]. There are several case reports of
Continuous analgosedation with midazolam and sufentanil was chemical meningitis and epileptic seizures following spinal or
administered intravenously. Microbiological analysis of CSF and epidural anaesthesia with bupivacaine [6-13]. To the best of our
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knowledge, this is the first report of generalized epileptic seizures Conclusion
after the administration of levobupivacaine. Levobupivacaine is In conclusion, we described a patient with generalized epileptic
a long-acting, amide-type local anesthetic with a clinical profile seizures following spinal analgesia with levobupivacaine. Our
closely resembling that of bupivacaine. However, preclinical study demonstrates that chemical meningitis and generalized
toxicity and safety data show an advantage for levobupivacaine epileptic seizures should be among the differential diagnoses of
over bupivacaine [14]. Anesthetics from the amide group may lead complications occurring in patients undergoing epidural or spinal
to central nervous system (CNS) symptoms, such as seizures or an anaesthesia, especially in certain populations such as pregnant
altered mental state. An animal study demonstrated that the small, women, although these agents have been mostly associated with
moderate thorn-like complexes in the amygdaloid nucleus can lead transient neurological symptoms [6]. As unrecognized chemical
to generalized seizures; they result from local anesthetics in the meningitis and/or generalized epileptic seizures can lead to severe
amide group and are dose-dependent [7]. morbidity and mortality, early diagnosis and appropriate treatment
are essential for a successful recovery.
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© 2017 Predrijevac A, et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License

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