Presented at the 2012 AAPM Annual Meeting « Back

Two Episodes of Herpes Simplex Virus Meningitis Following Intrathecal Pump Refill

Edward J. Shen, MD, eshen@hmc.psu.edu¹, Jill M. Eckert, DO¹, Vitaly Gordin, MD¹, (1) Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania

Background: Implantable intrathecal opioid delivery systems have been used effectively to treat select patients with intractable chronic pain conditions. Indications for the use of intrathecal opioid infusion have expanded to include multiple chronic nonmalignant pain states. However, this treatment is not without side effects and complications. Objective: We present a case of two episodes of herpes simplex virus meningitis following intrathecal pump refills. We believe this is the first reported case of HSV reactivation associated with intrathecal pump refill. Case Report: A 55-year-old male with failed back surgery syndrome has an intrathecal pump with satisfactory pain relief. The patient had a refill of his intrathecal pump with hydromorphone, and approximately two weeks later he developed back pain, nausea, and headache. He was admitted and blood and cerebrospinal fluid cultures were obtained. The HSV polymerase chain reaction was positive. All other studies were negative. He was treated with oral acyclovir and symptoms resolved. The patient was asymptomatic for the next 9 months. During this period he had three intrathecal pump refills without recurrence. Seven days following the fourth intrathecal pump refill, the patient was admitted for a repeat episode of HSV meningitis confirmed by PCR. During the second episode he was again treated with acyclovir, however, he developed renal failure and acyclovir was discontinued. No further treatment was necessary as symptoms resolved. Results: The patient has subsequently received 11 additional pump refills without incident. Conclusion: Although rare, intrathecal hydromorphone refill can potentially reactivate HSV virus and cause meningitis. References: 1)Smith TJ, Staats PS, Deer T, Stearns IJ, Rauck RL, Boortz-Marx RL, Buchser E, Catala E, Bryce DA, Coyne PJ, Pool GE. Implantable Drug Delivery Systems Study Group: Randomized clinical trial of an implantable drug delivery system compared with comprehensiv 2)Anderson VC, Burchiel KJ. A prospective study on long-term intrathecal morphine in the management of chronic nonmalignant pain. Neurosurgery 1999; 44:289-300 3)Kumar K, Kelly M, Pirlot T. Continuous intrathecal morphine treatment for chronic pain of nonmalignant etiology: Long-term benefits and efficacy. Surg Neurol 2001; 55:79-86 4)Angel IF, Gould HJ, Carey ME. Intrathecal morphine pump as a treatment option in chronic pain of nonmalignant origin. Surg Neurol 1998; 49:92-8 5)Arduino P, Porter S. Herpes simplex virus type 1 infection: overview on relevant clinico-pathological features. J Oral Pathol Med 2008;37:107-21 6)Whitley RJ, Lakeman F. Herpes simplex virus infections of the central nervous system: Therapeutic and Diagnostic Considerations. Clin Infect Dis 1995;20:414-20 7)Tedder DG, Ashley, R, Tyler KL, Levin MJ. Herpes simplex virus infection as a cause of benign recurrent lymphocytic meningitis. Ann Intern Med 1994;121:334-38 8)Bergstrom T, Vahlne A, Alestig K, Jeansson S, Forsgren M, Lycke E. Primary and recurrent herpes simplex virus type 2-induced meningitis. J Infect Dis 1990;162:322-30 9)Bauchat JR. Neuraxial morphine and oral herpes reactivation in the obstetric population. Anesth Analg 2010;111:1238-41 10)Davies PW, Vallejo M, Shannon KT, Amortegui AJ, Ramanathan S. Oral herpes simplex reactivation after intrathecal morphine: a prospective randomized trial in an obstetric population. Anesth Analg 2005;100:1472-76

Funding: None