title: Allogeneic epidural blood patch in the setting of persistent spinal headache and disseminated coccidioidomycosis.
abstract: In most cases of post-dural puncture headache, the positional symptoms will resolve spontaneously within 2 weeks. Conservative therapies include oral analgesics and hydration, bed rest, and abdominal binders. For refractory cases, an autologous epidural blood patch remains the treatment of choice. However, in certain cases the use of autologous blood for the blood patch may place the patient at risk for infectious or malignant contamination of the central nervous system. Coccidioidomycosis results from inhalation of the arthroconidia (spore) stage of the fungal lifecycle. The most common manifestation of coccidioidomycosis is acute pulmonary symptoms, while the most feared complication is meningitis. Immunocompromised patients are at increased risk of fungemia; therefore, introduction of fungal elements into the central nervous system can occur if autologous blood is used for an epidural blood patch. We report a case of persistent dural-puncture headache in the setting of disseminated coccidioidomycosis. An autologous blood epidural blood patch was considered but deferred due to risk of coccidioidomycosis meningitis. Other epidural space interventions such as fibrin glue injection or saline infusions were judged to be too imprecise or ineffective. The patient was successfully treated with allogeneic blood donated by his wife, but only after testing of her blood as is required for any directed blood donation. Allogeneic epidural blood patches are an option for refractory dural puncture headaches when autologous blood may cause meningitis or malignant seeding of the central nervous system.
authors.affiliation: Department of Anesthesiology, Laboratory Medicine and Pathology, and Neurosurgery, Mayo Clinic, Phoenix, AZ 85054, USA. trentman.terrence@mayo.edu
authors.forename: Terrence L
authors.initials: TL
authors.lastname: Trentman
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Hoxworth
authors.forename: Shimon
authors.initials: S
authors.lastname: Kusne
authors.forename: A Sergio
authors.initials: AS
authors.lastname: Torloni
authors.forename: Naresh P
authors.initials: NP
authors.lastname: Patel
authors.forename: David M
authors.initials: DM
authors.lastname: Rosenfeld
mesh_terms: D000328:Adult; D017217:Blood Patch, Epidural / Q000009:adverse effects*; D001804:Blood Transfusion, Autologous / Q000009:adverse effects; D015170:Cerebrospinal Fluid Pressure; D003047:Coccidioidomycosis / Q000150:complications*; D000075202:Contraindications; D004388:Dura Mater / Q000601:surgery; D020773:Headache Disorders / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D019585:Intracranial Hypotension / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D008297:Male; D011183:Postoperative Complications / Q000503:physiopathology / Q000628:therapy*; D013129:Spinal Puncture / Q000009:adverse effects*; D013353:Subdural Effusion / Q000209:etiology / Q000517:prevention & control / Q000628:therapy; D014184:Transplantation, Homologous / Q000592:standards; D016896:Treatment Outcome