title: Case report: epidural abscess in a parturient with pruritic urticarial papules and plaques of pregnancy (PUPPP).
abstract: OBJECTIVE
  To describe the risk factors for epidural abscess (EA) formation following epidural analgesia in a parturient with pruritic urticarial papules and plaques of pregnancy (PUPPP).
  
  
  METHODS
  A 33 yr-old gravida 2 nulliparous patient at 36 weeks gestation presented with severe pre-eclampsia, and PUPPP (treated with prednisone). Magnesium prophylaxis was started and labour was induced. An epidural catheter was placed at the L(3-4) level using standard aseptic technique. Bupivacaine was incrementally injected to achieve a T10 sensory level, and analgesia was maintained using a continuous infusion of 0.0625% bupivacaine with fentanyl. Nine days post-delivery, the patient developed back pain radiating to her right leg, but she was otherwise asymptomatic. She was afebrile; with a slightly tender, non-erythematous, non-draining, 1 cm nodule at the epidural catheter site. Motor and sensory examinations were normal at that time. However, the patient returned 24 hr later and further investigations revealed: WBC 17,800.mm(-3), platelets 486,000.mm(-3), erythrocyte sedimentation rate 50 mm.hr(-1), and C-reactive protein 8.8 mg.dL(-1). The magnetic resonance imaging demonstrated an EA at the L(3-4) level causing minimal cord compression. The patient underwent an emergency decompressive laminectomy. Cultures revealed methicillin-sensitive Staphylococcus aureus. Her pain improved, and she was discharged on the third postoperative day with a six-week course of iv ceftriaxone.
  
  
  CONCLUSIONS
  Causative organisms for EAs include coagulase-negative Staphylococci, S. aureus, and Gram-negative bacilli. Infection can occur either hematogenously or by direct contamination during catheter placement. Risk factors include immunocompromised states and PUPPP, as with the case of this patient.
authors.affiliation: Department of Regional Practice Anesthesiology, Hillcrest Hospital, 6780 Mayfield Road, Mayfield Heights, Ohio 44124, USA. cummink2@ccf.org
authors.forename: Kenneth C
authors.initials: KC
authors.lastname: Cummings
authors.forename: James A
authors.initials: JA
authors.lastname: Dolak
mesh_terms: D000328:Adult; D000767:Anesthesia, Epidural / Q000009:adverse effects*; D020802:Epidural Abscess / Q000453:epidemiology / Q000209:etiology*; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007751:Labor, Induced; D011225:Pre-Eclampsia; D011241:Prednisone / Q000627:therapeutic use; D011247:Pregnancy; D011248:Pregnancy Complications / Q000188:drug therapy; D011537:Pruritus / Q000188:drug therapy; D012307:Risk Factors; D012871:Skin Diseases / Q000188:drug therapy; D013203:Staphylococcal Infections / Q000453:epidemiology / Q000209:etiology*; D014581:Urticaria / Q000188:drug therapy
chemical_list: D005938:Glucocorticoids; D011241:Prednisone