Recurrence of Herpes Simplex Virus Blepharitis After Cesarean by chenmeixiu

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									Recurrence of Herpes Simplex Virus Blepharitis                                                                             After
Cesarean Section and Epidural Morphine
Christopher         F. James,          MD
Department     of Anesthesiology,       University   of Florida   College   of Medicine,    Gainesville,    Florida




N      umerous case reports and a few studies have                               After magnesium       sulfate was administered          as a 4-g bolus
       associated the recurrence of oral herpes simplex                       followed by a 2-g/h infusion, the patient underwent                      epi-
       virus (HSV) infections involving the third divi-                       dural anesthesia and cesarean section. Epidural lidocaine 2%
                                                                              with epinephrine      (1:200,000) in divided doses for a total of
sion of the trigeminal nerve with epidural or spinal                          18 mL was administered;             epidural     fentanyl, 100 pg, was
opiates, especially morphine (l-8). Two recent pro-                           added prior to incision. The patient tolerated the procedure
spective studies, however, had conflicting results: In                        well, and the l- and 5-min Apgar scores for the neonate were
one, the effects of neuraxial morphine and parenteral                         both 9. Prophylactic       cefazolin, 2 g, was administered            intra-
opioids did not differ significantly (9). In the other, the                   venously. Toward the end of the procedure, epidural mor-
incidence of HSV was 11 times higher with epidural                            phine, 3.5 mg, was administered            for postoperative     pain con-
morphine than with parenteral morphine (10). Fur-                             trol. The next morning, approximately                18 h after epidural
                                                                              morphine had been administered,              the patient had mild facial
thermore, two large retrospective reports also had                            pruritus   of unknown        duration     that did not require treat-
conflicting results: The incidence of HSV was zero                            ment. At that time, the patient was not aware of itching, only
with intrathecal morphine (0.2 mg) in one (11) and                            that she was rubbing her face. The pruritus was not localized
3.5% with epidural morphine in the other (12). Despite                        to any one side or area.A second dose of epidural morphine,
the reported cases of oral HSV infection, however,                            3 mg, was administered           24 h after the first dose, and the
there have been no reported cases of recurrent HSV                            epidural    catheter was removed. The patient reported                      no
                                                                              itching or any other side effects on the second postoperative
blepharitis involving the first and second divisions of
                                                                              day. She was pain free until 30 h after the second dose of
the trigeminal nerve without third division involve-                          epidural    morphine,      when she complained             of abdominal
ment after epidural morphine. This report describes a                         cramping and mild incisional pain, which was treated with
parturient who experienced recurrent HSV blepharitis                          ibuprofen, 600 mg orally.
three days after surgery and two days after the second                            Three days after surgery and 2 days after the second dose
dose of epidural morphine for pain control after ce-                          of epidural     morphine,      the patient developed          right-sided
sarean section.                                                               vesicular lesions involving the lower eyelid, the upper cheek
                                                                              area, and the area lateral to the lateral palpebral                 fissure;
                                                                              early erythematous       lesions of the upper eyelid; and injected

Case Report
A 28-yr-old woman, gravida 1 para 0, at 39 wk gestation was
admitted for cesarean section. On the day of admission, she
had an acute increase in blood pressure of 140/95 mm Hg
and a routine positive contraction stress test with an unfa-
vorable cervix (closed and ~30% effacement).           During a
clinic visit 3 days earlier, her blood pressure was 130/80 mm
Hg. During gestation, her blood pressure ranged from 120 to
130 systolic mm Hg and 70 to 82 mm Hg diastolic. Except for
gestational diabetes mellitus, which was diet controlled, the
patient had a benign gestational course up to the day of
admission. Her medical history was unremarkable            except
for pilonidal     cyst removal at 15 yr of age and right-sided
periorbital   cellulitis of unknown origin that was treated with
antibiotics at 24 yr of age.

  Accepted for publication January 26, 1996.                                  Figure     1. Photograph     of early erythematous     (A) and vesicular (B)
  Address correspondence to Editorial Office, Department of An-               lesions of a herpes simplex          virus infection that developed     3 days
esthesiology, University of Florida College of Medicine, Box 100254,          after surgery     and 2 days after the second dose of epidural      morphine
Gainesville, EL 32610-0254.                                                   administered       for pain control after cesarean section.


                                                                                                   01996 by the International   Anesthesia Research Society
10%     An&h    Anal8 1996;82:1094-6                                                                                                      0003-2999/96/$5.00
ANESTH        ANALG                                                                                           CASE   REPORTS         1095
1996;82:10944




Table 1. Reports of the Incidence of Herpes Simplex Virus (HSV) After Neuraxial Morphine Compared with After
Parenteral dpioids
                                                                                                          Incidence of HSV
                                                                                                        (% [total n in group])
          Year of             Population     Neuraxial morphine             Parenteral opioids         Neuraxial       Parenteral
          report               size (n)         (route, dose)               (drug, route, dose)        morphine         opioids
     1987 (1)                          44   Epidural, 5 mg initially   Morphine, IM, 10 mg every        34.6 (26)          0 (18)
                                              and 3-5 mg repeated       6 h as needed
    1988 (2)
    Retrospective                    291    Epidural, 4-5 mg           Unknown                           9.7 (134)       0.6 (157)
    Prospective                      729    Epidural, 4-5 mg           Unknown                           4.9 (146)       0.5 (583)
    1990 (3)                         187    Epidural, 4-5 mg           Meperidine, IM, 50-100 mg,       14.6(96)            0 (91)
                                                                        or morphine, IM, 7.5-10 mg
     1994 (9)                        357    Epidural, 3-5 mg, or       Unknown                           3.5 (201)       2.6 (156)
                                              spinal, 0.15-0.25mg
     1995 (10)                       811    Epidural, dose             Morphine, IV or IM, dose          5.2 (425)       0.5 (386)
                                              unknown                   unknown
    IM, intramuscular;   IV, intravenous.



conjunctiva of the right eye (Figure 1). Out of concernfor eye          one of many contributing factors (such as the hor-
involvement, an ophthalmologic consultation was obtained.               monal effects of pregnancy, immunosuppression, and
The diagnosisof recurrent HSV infection was confirmed by
                                                                        stress of the procedure), is not clear. Many have at-
Tzanck smear.The patient reported having suffered a HSV
infection of the right upper eyelid and cheek2 yr earlier after         tempted to associate pruritus, a common side effect of
excessiveexposure to sunlight. At that time, the lesionshad             neuraxial opiates (especially morphine), with the sub-
been confined to the upper eyelid and upper cheek. During               sequent development of HSV (l-3,8,9). Opioid-related
the most recent infection, the conjunctiva was cultured and             pruritus can be generalized or can be localized-either
found not to be infected and the cornea was clear. Trifluri-            to the dermatome where the injection was adminis-
dine 1% was administered as drops to the eyes, and acyclo-
vir ointment was used to treat the affected skin. The patient           tered or, more commonly, to the facial region, proba-
was discharged from the hospital the next day. A follow-up              bly involving the trigeminal ganglion (15,16). Except
ophthalmologic examination revealed that her lesionshad                 for two studies reporting no correlation between oral
resolved.                                                               lesions and either generalized or facial pruritus (9,10),
                                                                        most studies report that the majority of women who
                                                                        experience recurrent HSV infection complain of facial
Discussion                                                              itching. Extensive facial pruritus may cause significant
Recurrent HSV infection can be exacerbated by exog-                     skin trauma, which, in turn, may incite recurrent HSV
enous factors, such as sunlight, wind, trauma, and                      lesions. However, because pruritus and a burning
fever, or by endogenous sources related to physiologic                  pain are classic prodromes to erythema and subse-
states, such as stress. Although not necessarily causal,                quent grouped vesicular eruptions, pruritus could
recurrent HSV infection has followed the use of                         also just be an early manifestation of HSV reactivation
neuraxial opiates for analgesia after cesarean section                  and not an inciting factor.
(l-8,10,12). In most cases, epidural and spinal mor-                       This report describes a term pregnant patient who
phine were used, but epidural fentanyl (7) and spinal                   had recurrent HSV blepharitis three days after sur-
meperidine (5) have also been implicated.                               gery. Unlike those in other reports, this patient man-
    Up to 40%-50% of the US population may suffer                       ifested recurrent HSV in the first and second divisions
recurrent HSV infections (13). Moreover, in one study                   of the trigeminal nerve alone (ophthalmic and maxil-
of women with a history of HSV infection from the                       lary), as opposed to the more typical third division
fifth month of gestation until delivery, up to 84% had                  (mandibular). Extension of HSV lesions to the nose
a documented recurrence during pregnancy (14),                          and infraorbital areas from preexisting and more typ-
which renders the association between neuraxial opi-                    ical oral lesions has been mentioned (3,8). The other
ates and recurrent infection during this period more                    possible contributing factor in this case was that the
suspect.                                                                patient received two separate doses of epidural mor-
    The incidence of recurrent HSV infection has been                   phine totaling 6.5 mg. Most of the other reports also
compared between those who did and did not have                         involved large doses of neuraxial opioids (1,4-7). In
epidural or spinal opiates (Table 1). Whether neuraxial                 the original study, there was a 34.6% incidence of HSV
morphine and other opiates are the main cause of                        in patients receiving multiple doses of epidural mor-
recurrent HSV infection after cesarean section, or just                 phine (1). Whether this large dose had any bearing on
1096      CASE    REPORTS                                                                                                                                             ANESTH        ANALG
                                                                                                                                                                          1996;82:1094-6




the present case is uncertain. Although epidural mor-                                        6. Pennant JH, Wallace             D. Intrathecal       morphine         and reactivation
                                                                                                of oral herpes simplex            [correspondence].           Anesthesiology           1991;
phine and reactivation     of HSV appeared to be associ-                                        75:167.
ated in this case, it is unclear whether the relationship                                    7. Valley MA, Bourke             DL, McKenzie          AM. Recurrence             of thoracic
was causal. Unfortunately,       the information   about the                                    and labial herpes simplex              virus infection        in a patient receiving
patient’s history of HSV was not obtained until after                                           epidural    fentanyl.      Anesthesiology          1992;76:1056-7.
                                                                                             8. Douglas      MJ, McMorland             GH. Possible          association        of herpes
the reactivation.
                                                                                                simplex type I reactivation             with epidural        morphine        administra-
   A history of HSV infection involving less common                                             tion [correspondence].            Can J Anaesth         1987;34:426.
areas should be viewed with more caution than peri-                                          9. Norris    MC, Weiss J, Carney              M, Leighton         BL. The incidence            of
oral infections due to the potentially         more harmful                                     herpes simplex virus labialis after cesarean delivery.                        Int J Obstet
                                                                                                Anesth 1994;3:127-31.
sequelae of ophthalmic        and central nervous system                                    10. Boyle RK. Herpes            simplex     labialis after epidural            or parenteral
manifestations,   such as HSV keratoconjunctivitis       and                                    morphine:      a randomized           prospective       trial in an Australian            ob-
meningitis (13,17).                                                                             stetric population.         Anesth Intensive          Care 1995;23:433-7.
                                                                                            11. Abouleish      E. Intrathecal       morphine       as a cause for herpes simplex
                                                                                                should be scratched           out [correspondence].            Anesthesiology          1991;
                                                                                                75:919.
References                                                                                  12. Fuller JG, McMorland               GH, Douglas           MJ, Palmer          L. Epidural
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