Herpes Zoster – An Uncommon Complication of Spinal Anesthesia
J Danny Muehlschlegel, MD. and Felipe Urdaneta,
MD.
Department of Anesthesiology, University of Florida, Gainesville, Florida
ABSTRACT
Introduction: Surgical procedures, general and regional anesthesia are
associated with immunosuppression and a reduction of natural killer cell
activity (1). Herpes Zoster is a viral disease that affects the posterior
root ganglia, posterior nerve roots, and dorsal horns. Persistent sensory
deficits can result (2). A relation between the neurologic deficit of spinal
anesthesia and herpes zoster has been described but never established (3).
We present a case of herpes zoster infection in the dermatomal distribution
of a lumbar spinal anesthesia in an immunocompetent patient.
Case Report: 65yo man with a medical history of obesity and severe
obstructive sleep apnea (OSA), Diabetes Mellitus Type II, hypertension and
chronic venous stasis ulcers was diagnosed with bladder stones. His urine
culture grew Candida tropicalis and he received 1 week of Amphotericin B
bladder washings and 15 days of oral Diflucan. He was scheduled for
transurethral resection of the prostate, cystoscopy and laser cystolithopexy.
After administration of 1mg of Versed a spinal anesthesia was performed
using an introducer, a 22g Whitacre needle and 12mg of hyperbaric Tetracaine
in the L3-L4 interspace. No parasthesia was noted, a T8 sensory level was
obtained and the patient tolerated the procedure well. He received no
additional narcotic/anesthetic due to concerns of his OSA. On postoperative
day #2 (POD#2), the patient developed isolated back pain close to the lumbar
puncture site without visible lesions and on POD#3, left leg pain and
macular hemorrhagic slightly crusting lesions extending from the site of the
previous spinal injection down to buttock and L lateral thigh corresponding
with the L4 dermatome. Upon consulting Dermatology, a presumptive diagnosis
of Herpes Zoster was made, a biopsy was obtained and the patient was started
on 800mg PO Acyclovir 5x/day for 7 days with improvement in pain and rash
after three days. Varicella/Zoster virus IgG was found in serum, confirming
an acute infection. The biopsy was sent for viral culture, but since the
varicella–zoster virus is labile and relatively difficult to recover from
cutaneous lesions, it was negative(2). Unfortunately, the direct
immunofluorescence assay was not available.
Discussion: Surgery and anesthesia are known immunosuppressive states and
can predispose to reactivation of varicella zoster virus infections, due to
a reduction in natural killer cells. The effects of regional anesthesia are
controversial. Trauma to the nerve, nerve root or ganglion during regional
procedures and/or surgical manipulation has been associated with zoster.
Other studies have shown that regional anesthesia may attenuate
immunosuppressive effects; (4) and regional central axial as well as
stellate ganglion blocks have been shown to shorten the duration of
treatment and may reduce the incidence of and even prevent post herpetic
neuralgia (5,6). In our case there were however no episodes of parasthesia
during the procedure. Our patient responded well to acyclovir and did not
develop post herpetic neuralgia. Given the dermatomal distribution of his
eruption, our patient would have been a questionable candidate for a
regional anesthestic for the treatment of pain. In conclusion, we present a
case of acute herpes-zoster infection confirmed by serology after-spinal
anesthesia in an immunocompetent individual where the dermatomal
distribution of the lesions correlated with the site of the dural puncture.
References:
1. Kutza J, et al. 1997. Anesth Analg 85: 918-23
2. Gnann JW, Jr., et al. 2002. N Engl J Med 347: 340-6
3. Junke E, et al. 1987. Ann Fr Anesth Reanim 6: 523-4
4. Le Cras AE, et al. 1998. Anesth Analg 87: 1421-5
5. Manabe H, et al. 1995. Clin J Pain 11: 220-8
6. Higa K, et al. 1998. Reg Anesth Pain Med 23: 25-9
