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| LETTERS TO EDITOR |
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| Year : 2019 | Volume
: 67
| Issue : 1 | Page : 268-269 |
Spontaneous spinal epidural hematoma and septic encephalopathy secondary to postpartum septicemia
Sucharita Anand1, Vimal K Paliwal1, Zafar Neyaz2, Arun K Srivastava3
1 Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| Date of Web Publication | 7-Mar-2019 |
Correspondence Address:
Dr. Vimal K Paliwal
Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow - 226 014, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.253608
How to cite this article:
Anand S, Paliwal VK, Neyaz Z, Srivastava AK. Spontaneous spinal epidural hematoma and septic encephalopathy secondary to postpartum septicemia. Neurol India 2019;67:268-9 |
How to cite this URL:
Anand S, Paliwal VK, Neyaz Z, Srivastava AK. Spontaneous spinal epidural hematoma and septic encephalopathy secondary to postpartum septicemia. Neurol India [serial online] 2019 [cited 2022 May 26];67:268-9. Available from: https://www.neurologyindia.com/text.asp?2019/67/1/268/253608 |
Sir,
Spontaneous spinal epidural hematoma (SSEH) is rare during the pregnancy/postpartum state. In a majority of cases, the underlying cause is not known.[1] Rarely SSEH is caused by epidural anesthesia, HELLP syndrome (hemolysis, elevated liver enzymes, and a low platelet count), chiropractic maneuvers, coagulation abnormality, or is associated with myelitis.[2],[3] In this report, we describe a postpartum patient with septicemia, septic encephalopathy, and spinal epidural hematoma.
A 28-year old lady complained of weakness of both legs on recovering from her unconsciousness. She suffered from multiple generalized tonic–clonic seizures and loss of consciousness on her 7th postpartum day (she delivered a full-term baby by normal vaginal delivery). She only had low-grade fever 2 days prior to suffering from unconsciousness. There was no history of seizures, hypertension, diabetes mellitus, or pedal edema. Her antepartum and intrapartum periods were uneventful. She did not receive any epidural analgesia. At the time of admission, the patient was in shock (systolic blood pressure 60 mmHg), and was comatose (Glasgow Coma Scale E1M2V1). Her pupils were normal in size/reaction and fundus showed splinter hemorrhages. Her deep tendon jerks were brisk and both planters were extensor. Per abdomen examination revealed the fundal height to be just below the umbilicus. After regaining consciousness, her examination revealed complete paraplegia below thoracic (T) vertebral segment T4 (ASIA impairment scale A).
Her investigations revealed the total leukocyte count of 26000/cumm, (polymorphs 90%), platelet count of 46000/cumm, aspartate aminotransferase (AST)/alanine aminotransferase (ALT) level of 364/445 IU/L, normal activated partial thromboplastin time (APTT)/prothrombin time (PT)/international normalized ratio (INR) values, a serum creatinine level of 5.6 mg/dl, a serum urea level of 154 mg/dl, a normal urine examination, and a high procalcitonin, d-dimer, and a normal fibrinogen level. Her ultrasound abdomen revealed a bulky uterus without any retained products of conception. Her blood culture grew significant growth of Escherichia More Details coli that was sensitive to meropenem. Her magnetic resonance imaging (MRI) of the brain revealed multiple punctate hemorrhages [Figure 1]. The patient was electively intubated and mechanically ventilated. Her blood pressure was maintained by adequate hydration, inotropes, and control of infection with antibiotics. The seizures responded to a loading dose of levetiracetam. She required multiple sessions of hemodialysis for uremia. She regained consciousness over the next 2 weeks after control of septicemia and renal failure. Her spinal MRI revealed an epidural hematoma extending from T8 to T12 vertebral levels compressing the cord [Figure 1]. Urgent surgical evacuation of the hematoma was performed. However, there was no improvement in her motor or sensory functions even after 2 weeks of her undergoing surgery. | Figure 1: (a-d) Cranial MRI susceptibility-weighted images (SWI) showing multiple areas of blooming suggestive of hemorrhage; (e) spinal MRI T2-weighted image showing an acute epidural hematoma extending from T8 to T12 vertebral segments compressing the spinal cord
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To the best of our knowledge, SSEH has not been described secondary to postpartum septicemia. The scoring criteria based on the global coagulation tests (platelet count, prothrombin time, fibrin-related markers, and fibrinogen levels) revealed a score of <5, suggestive of the presence of a nonovert disseminated intravascular coagulation (DIC).[4] However, the presence of splinter hemorrhages in the retina, multiple punctuate areas of hemorrhage in the brain, and the epidural spinal hematoma was suggestive of coagulopathy (nonovert), in all likelihood, due to septicemia. Lack of evidence of ongoing hemolysis was against the possibility of HELLP syndrome, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome. Elevated procalcitonin also favored the possibility of septicemia. Septicemia alters the coagulation cascade, thereby resulting in a bleeding tendency.[5] Though the coagulation abnormality is generalized, bleeding manifestations occurs locally in areas with dysfunctional vasculature. Moreover, septicemia produces alteration in the blood flow to vital organs, thereby resulting in cytopathic hypoxia, thus adding to the injury.[5]
Previous reports have shown a good response to the prompt evacuation of the spinal hematoma in patients with SSEH.[6] However, a delayed diagnosis in our patient due to profound sensorial abnormality early in course of the illness, and the presence of a severe grade of spinal cord injury were the reasons for a poor recovery. Our case highlights that postpartum septicemia may produce SSEH despite the absence of an overt coagulopathy. A higher index of suspicion is required because only an early initiation of surgical treatment is known to produce favorable results.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| » References | |  |
| 1. | Krishnan P, Kartikueyan R. Spontaneous spinal epidural hematoma: A rare cause of paraplegia in pregnancy. Neurol India 2014;62:205-7.  [ PUBMED] [Full text] |
| 2. | Cetinalp NE, Oktay K, Ozsoy KM. Spontaneous spinal epidural hematoma mimicking a cerebrovascular disease. Neurol India 2017;65:1434-5. [ PUBMED] [Full text] |
| 3. | Wang ZL, Bai HX, Yang L. Spontaneous spinal epidural hematoma during pregnancy: Case report and literature review. Neurol India 2013;61:436-7. [ PUBMED] [Full text] |
| 4. | Toh CH, Alhamdi Y, Abrams ST. Current pathological and laboratory considerations in the diagnosis of disseminated intravascular coagulation. Ann Lab Med 2016;36:505-12. |
| 5. | Remick DG. Pathology of sepsis. Am J Pathol 2007;170:1435-44. |
| 6. | Henry JB, Messerer M, Thomas V, Diabira S, Morandi X, Hamlat A. Nontraumatic spinal epidural hematoma during pregnancy: Diagnosis and management concerns. Spinal Cord 2012;50:655-60. |
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