Severe symptomatic aseptic chemical meningitis following myelography

Bender, Andreas; Elstner, Matthias; Paul, Robert; Straube, Andreas

doi:10.1212/01.wnl.0000140698.98701.78

Cited by 18 publications

(11 citation statements)

References 9 publications

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“…10 Myelography with iotrolan has also been shown to result in symptomatic aseptic chemical meningitis. 11,12 Further, hydrocephalus after myelography with iotrolan has been reported, possibly due to arachnoiditis, hypersensitivity reaction, or dural sinus thrombosis. 13 Rhabdomyolysis secondary to anticonvulsant-resistant seizures following myelography with iohexol, a nonionic contrast medium, has also been reported.…”

Section: Discussionmentioning

confidence: 99%

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Encephalopathy and rhabdomyolysis induced by iotrolan during epiduroscopy

Mizuno

Gauss

Suzuki

et al. 2007

Can J Anesth/J Can Anesth

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CAN J ANESTH 54: 1 www.cja-jca.org Januar y, 2007Purpose: We describe a complication of epiduroscopy with encephalopathy and rhabdomyolysis associated with the contrast medium iotrolan. Clinical features:A 76-yr-old man with failed back surgery syndrome underwent epiduroscopy. Sufficient lysis could not be achieved in the epidural space above the level of L 4 due to dense adhesions and scar tissue. After epidural injections of iotrolan and mepivacaine, he developed motor weakness and hypoesthesia in both legs, which lasted for three hours. He also became confused, agitated, disoriented, and developed neck stiffness and tremors involving the head and legs. Computed tomography revealed diffuse contrast enhancement within the intracranial cerebrospinal fluid (CSF) spaces, indicating an intraoperative dural tear. Marked increases in serum creatinine phosphokinase and myoglobin indicated subsequent acute rhabdomyolysis. Crystalloid infusion and semi-recumbent positioning facilitated iotrolan absorption from the CSF, and the patient recovered uneventfully. Conclusions:Dural tear during epiduroscopy may allow access of contrast media into the CSF. Neurotoxicity secondary to iotrolan within the CSF was a likely contributing factor to the encephalopathy and subsequent rhabdomyolysis. This is an instructive example of the importance of diagnosing inadvertent dural tear during epiduroscopy under iotrolan, for avoidance of adverse events such as encephalopathy and rhabdomyolysis. Eléments cliniques : Un homme de 76 ans présentant des séquelles d'un échec d'une chirurgie aux rachis a subi une épidur-oscopie. Une lyse suffisante n'a pas pu être obtenue dans l'espace péridural au-dessus de L 4 à cause d'adhésions denses et de tissus cicatriciels. Suite à des injections péridurales d'iotrolan et de mépivacaïne, il a développé une parésie ainsi qu'une hypoesthésie au niveau des membres inférieurs qui durèrent trois heures. Il est également devenu confus, agité, désorienté, et a développé une raideur du cou et des tremblements de la tête et des jambes. La tomodensitométrie a révélé un rehaussement diffus du produit de contraste dans les espaces intracrâniens du liquide céphalo-rachidien (LCR), indiquant

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Section: Discussionmentioning

confidence: 99%

“…While use of a lumbar intrathecal catheter has been described for the purpose of performing drainage and lavage of the intrathecal space, 11,13,18 we would warrant caution for the introduction of another invasive procedure without clear indications.…”

Section: Discussionmentioning

confidence: 99%

Encephalopathy and rhabdomyolysis induced by iotrolan during epiduroscopy

Mizuno

Gauss

Suzuki

et al. 2007

Can J Anesth/J Can Anesth

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“…The patient's mental status improved 72 hours after the myelogram, and his fever resolved by 120 hours. Two cases of aseptic meningitis with iotrolan myelography 7,8 and 2 cases of aseptic meningoencephalitis with iopamidol myelography 11,12 have also been described.…”

Section: Discussionmentioning

confidence: 99%

“…Negative results on CSF cultures are a requisite. Bender et al 7 proposed measuring serum procalcitonin levels as a guide to help differentiate between bacterial and aseptic chemical meningitis because procalcitonin levels are higher in bacterial infections.…”

Section: Discussionmentioning

confidence: 99%

Aseptic Meningoencephalitis after Iohexol CT Myelography

Romesburg¹,

Ragozzino²

2008

AJNR Am J Neuroradiol

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SUMMARY:We describe the case of a patient with aseptic meningoencephalitis after intrathecal iohexol injection for myelography and review the previous literature on similar cases of contrastinduced neurotoxicity.A septic meningoencephalitis is a rare complication of myelography with nonionic, iodinated, water-soluble contrast agents. We describe a case of a 69-year-old woman in whom aseptic meningoencephalitis developed after she underwent iohexol myelography. Case ReportA 69-year-old white woman underwent a technically successful outpatient CT myelogram with 10 mL of iohexol (Omnipaque 300; GE Healthcare, Cork, Ireland). The CSF was clear and colorless, and myelogram revealed degenerative osteoarthritis and severe central canal stenosis at L3-L4 secondary to short pedicles, facet and ligamentum flavum hypertrophy, and diffuse disk bulging. Approximately 12 hours after the injection, she experienced fever, headache, confusion, agitation, and aphasia. She was brought to the emergency department 20 hours after the myelogram.In the emergency department, her initial temperature was 102.5°F, and she was agitated and unable to speak, though she could shake and nod her head for "yes" or "no" responses. She complained of a severe headache and low back pain but denied incontinence or lower extremity numbness. On physical examination, she had mild symmetric lower extremity weakness that measured 4 of 5 bilaterally. Her serum white blood cell count (WBC) was 24,300 cells/L (90% neutrophils). Head CT revealed moderate to severe, chronic, smallvessel ischemic disease. Lumbar puncture and CSF analysis approximately 30 hours after the iohexol injection revealed turbid-appearing fluid with 300 white cells/L (61% polymorphonuclear cells and 1% monocytes), 5200 red cells/L, glucose level of 63 mg/dL, and elevated total protein level of 624 mg/dL. A second tube of CSF from the same lumbar puncture revealed 220 white cells/L (94% polymorphonuclear cells and 2% lymphocytes) and 1545 red cells/L. Results of CSF bacterial and cryptococcal antigens were negative. CSF culture revealed no growth at 5 days.She was initially started on intravenous ceftriaxone (2000 mg) and vancomycin (1000 mg) every 12 hours. The following day, approximately 48 hours after the myelogram, she was afebrile, and her mental status and neurologic examination had returned to near baseline with fluent speech. She was alert and oriented, with no recollection of the previous day, and complained only of a bandlike headache. An infectious disease consultation was obtained, and the patient was diagnosed with an allergic reaction to the iohexol. Diagnosis was based on the negative Gram stain result, negative culture result, and rapid resolution. Antibiotics were discontinued after results of CSF tests, blood tests, and urine cultures remained negative.

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“…Serum procalcitonin can discriminate between bacterial and chemical causes of meningitis [57]. CSF pleocytosis may range from 100 to several-thousand cells.…”

Section: Diagnostic Workupmentioning

confidence: 99%

Headache Attributable to Nonvascular Intracranial Disorders

Obermann

Holle

Naegel

et al. 2011

Curr Pain Headache Rep

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Headache attributable to nonvascular intracranial disorder is a basket of multiple, partly complex, and very diverse idiopathic or secondary disorders. By definition, the headache has to occur in a close temporal relationship to the intracranial disorder. Some of these headache disorders are caused by high or low cerebrospinal fluid pressure; noninfectious inflammatory diseases such as neurosarcoidosis, aseptic (noninfectious) meningitis, and lymphocytic hypophysitis; or intracranial neoplasm. Other nonvascular headaches, including hemicrania epileptica and postseizure headache, Chiari malformation type I, and the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis, are attributed to hypothalamic or pituitary hyper- or hyposecretion, intrathecal injection, or epileptic seizures. The clinical presentation of all these disorders can be diverse and often mimics the characteristics of primary headaches, which may delay the diagnosis.

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Severe symptomatic aseptic chemical meningitis following myelography

Cited by 18 publications

References 9 publications

Encephalopathy and rhabdomyolysis induced by iotrolan during epiduroscopy

Encephalopathy and rhabdomyolysis induced by iotrolan during epiduroscopy

Aseptic Meningoencephalitis after Iohexol CT Myelography

Headache Attributable to Nonvascular Intracranial Disorders

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