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Nurses in hospitals, especially those caring for HIV-positive or
failure, anemia, leukopenia, and thrombocytopenia. The major
drug-addicted patients
toxicities of isoniazid are on the peripheral nervous system, liver,
Pathologists and laboratory workers
and kidneys. Isoniazid-induced neuropathy can be prevented by
Respiratory therapists and physiotherapists
administration of pyridoxine and by a reduction of the isoniazid
Physicians in internal medicine, anesthesia, surgery, and psychiatry
dose in women who are slow acetylators.188
Nonmedical hospital personnel in housekeeping and transport work
Maternal clinical condition and the effects of treatment will
Funeral home employees
dictate the best anesthetic technique and anesthetic drugs. Care
Prison employees
must be taken to determine the extent of systemic involvement,
since nonpulmonary TB is common in reports of TB during preg-
nancy. Reported cases of TB during pregnancy have included
Table 18.8 Fundamental principles of the DOTS strategy for
TB peritonitis,189 spinal TB,190 and genital TB.191 Spinal TB
tuberculosis eradication186
might be considered a relative contraindication to neuraxial
block, but some cases of spinal TB have actually been discovered
Political will
after neuraxial block led to spread of the TB into the paraspinous
Diagnosis by sputum microscopy
muscles or after epidural analgesia was thought to have led to
Directly observed standardized short-course treatment
infection.192,193,194
Adequate supply of good quality drugs
Systematic monitoring and accountability

Schistosomiasis
Schistosomiasis (Katayama fever) results from infection with the
developed by the World Health Organization are known as the
DOTS strategy186 (directly observed therapy short-course; see parasitic flatworms Schistosoma mansoni, S. haematobium,
S. japonicum, (and rarely S. intercalatum, or S. mekongi). It is a
Table 18.8). Included in its five-element approach is direct obser-
common infection in tropical countries where bodies of water are
vation of treatment results, which now is considered by many to
be a standard of care in TB therapy.181 infested with snails of the Biomphalaria or Oncomelania genera.
It is not found in the United States, but 200 million people are
Clinical manifestations of TB include an unremitting cough,
infected worldwide.195 Infections with schistosomiasis occur dur-
fatigue, weight loss, loss of appetite, fever, hemoptysis, and night
ing immersion in infected waters where the larvae actively pene-
sweats. Tuberculosis may include both pulmonary and extrapul-
trate the skin and migrate predominantly to the bowel veins.
monary disease, and it mimics many disease states. In one case
Pruritus is a characteristic symptom after larval penetration and
series in pregnant women, CNS involvement was very common
the disease is sometimes known as Swimmer™s Itch. Clinical mani-
but symptoms suggestive of TB during the pregnancies were
festations and treatment are described in Table 18.9. The disease
uncommon. Tuberculosis should be considered in the differential
affects mainly children or childbearing women, who cook, wash
diagnosis of postpartum fever of unknown origin. Sputum
clothes, or work near contaminated lakes or rivers. It is popularly
microscopy is the most important conventional test for TB
known as ˜˜water belly™™ in Brazil, and can present as pseudo-
and is adequately specific but lacks sensitivity. Detection of
pregnancy because of ascites.
Mycobacterium tuberculosis by culture requires six to eight
Pregnant women from endemic regions may have chronic or
weeks. More ideal diagnostic procedures, e.g. polymerase chain
acute forms of the disease. Preoperative laboratory evaluations
reaction assays with excellent specificity and sensitivity for bacilli
include liver enzymes, albumin levels, hemoglobin level, coagu-
detection, and identification directly from clinical specimens,
lation tests, and renal function tests. Systematic ultrasonography
have been developed.
of the liver and spleen is used to diagnose and manage patients
Pregnancy does not change the course of tuberculosis but,
with chronic S. mansoni infection.199 Praziquantel appears to be
unless treated, TB poses a risk to the pregnant woman and her
safe to use during pregnancy and lactation, even in the first
fetus and peripartum TB is often severe. Treatment of pregnant
trimester.200,201 Antischistosomal vaccines have been investi-
women should be initiated whenever the probability of TB is
gated but none have been found effective to date. Although con-
moderate to high. Infants born to women with untreated TB
genital infections have been described in animal models, vertical
may be of lower birthweights than normal and, rarely, a baby
transmission appears unlikely or very rare in humans.202
may be born with TB. Although drugs used in the initial treatment
regimen cross the placenta, they do not appear to have harmful
fetal effects. The preferred initial treatment regimen is isoniazid,
Yersinia species (plague)203
rifampicin (RIF), and ethambutol daily for two months, followed
Plague occurs after humans are bitten by fleas infected with
by isoniazid and RIF daily, or twice weekly for seven months, and
Yersinia pestis and 1000“3000 cases occur annually worldwide at
nine months of total treatment. Breast-feeding is also safe during
present (10“20 yearly in the US). Plague is quickly progressive204
antituberculosis therapy. Pyrazinamide is reserved for women



332
Chapter 18


Vibrio cholerae (cholera)
Table 18.9 Schistosomiasis
Vibrio cholerae is the causative agent of cholera, a severe and
Clinical Infection may be asymptomatic. Usual course:
devastating diarrheal disease. Until 1992, epidemic and pan-
manifestations 20“60 days after contamination, febrile illness
demic cholera was associated only with the O1 serogroup of
with diarrhea, coughing (from lung
V. cholerae. Since then, the O139 (˜˜Bengal™™) serogroup has caused
infestations), abdominal pain, sudoresis, and
epidemic cholera in a number of countries.205,206,207 Epidemics of
anorexia; periportal thickening, liver
cholera are associated with contaminated water supply. Person-
parenchymal lesions, melenae, compensated
to-person transmission is rare.
or decompensated hepatosplenic syndrome,
Cholera-like illness is a low morbidity disease associated with
associated with grade II or III fibrosis and
eating unwashed fruits and vegetables, and drinking nonpasteurized
esophageal varices, hemorrhage,
milk and untreated water.208 After a few hours to three-day incuba-
nephropathy, and anemia. Rare associations
tion period, there is a severe acute diarrheal syndrome, with vomit-
include ischemic necrotizing colitis196 and
ing and dehydration equivalent to a loss of one liter of fluid per hour.
carcinoma of liver. Eosinophilia is a major
Vibrio cholerae is quite sensitive to acidic environments, which
finding in parasitic infections.196 Among 972
inhibit its growth, and consumption of a drink made from the
pregnant women surveyed in Tanzania, 63.5%
citrus fruit toronja (pH 4.1) was protective against cholera during
were infected with Schistosoma mansoni,
an epidemic in Peru. Consumption of toronja could be a useful
56.3% with hookworm, and 16.4 % with
cholera prevention strategy.209
malaria; 66.4% of the women were anemic.
The virulence of V. cholerae strains is, in general, ascribed to
Increased risk of anemia was associated with
enterotoxin production. Transmission occurs via infected human
heavy infection with Schistosoma mansoni but
excreta and may be seasonal. Prompt diagnosis is important for
not hookworm or Plasmodium falciparum
quick medical intervention. The Cholera ScreenTM is a highly
parasitemia.197
specific monoclonal antibody-based coagglutination test, with
Colonic polyposis, portal and pulmonary
the availability of results in less than five minutes.210,211 The
hypertension, cystitis, and glomerulonephritis
vibrio are generally sensitive to tetracycline, doxycycline, azithro-
may occur.
mycin, amoxicillin, betalactams, and fluoroquinolones.212,213
Treatment Oral praziquantel (a second dose nine days later
Oral cholera vaccines have been developed and have varying
is required to kill all eggs).198 Retaining a small
effectiveness.214,215 The provision of clean water and sanitation
number of S. mansoni may be advantageous to
is the most important preventive measure.216
people in endemic areas, in order to constantly
Preoperative care involves intense rehydration, correction of
prime the immune response. Alternative (for
electrolyte disturbances, and improvement in nutritional status.
S. mansoni only) is oxamniquine.
The pregnant patient should be hospitalized during the acute
phase of cholera. Anesthetic considerations in the acute phase
relate primarily to the management of clinical shock, i.e. ade-
and is characterized by bacteremia, high fever, delirium, and
quate peripheral and central line placement and rehydration.
coma with a mortality rate as high as 90%, if not treated. Initial
clinical signs include swollen and tender lymph nodes, fever,
chills, headache, and exhaustion. The bubonic form is named
Trypanosoma cruzi (Chagas disease)
for painful swelling of the lymph glands called buboes. Skin
Transmission of Tripanosoma cruzi to humans occurs when an
involvement and DIC cause red spots that turn black (hence
infected reduviid bug bites and then the bite or mucosa is soiled
the term “ the Black Death). Bubonic plague has an untreated
with contaminated feces containing trypomastigotes. Acute
mortality of 30“75% and can progress to multiple organ involve-
Chagas disease is usually a mild illness (lymphadenopathy and
ment and septicemia (nearly 100% fatal). The pneumonic form
˜
a unilateral periorbital edema known as the Romana sign). When
becomes an epidemic easily, through aspiration of aerosolized
the acute illness resolves, the patient enters the indeterminate
particles, but its very high mortality (90“95%) limits spread. When
phase, after which lifelong parasitemia may occur. Ten to thirty
diagnosed and treated, mortality is still about 15%.
percent of infected persons will develop chronic Chagas disease
Symptoms of plague take one to seven days to appear. Initial
years later. Chronic disease is characterized by denervation of
disease is marked by headaches, nausea, aching joints, fever
the cardiac conducting system, resulting in cardiomyopathy,217
(101“1058F), and vomiting. Buboes appear in the armpits, neck,
and/or denervation of the smooth muscle of the digestive tract,
and groin. In the pneumonic form, slimy blood-tinged sputum
resulting in megacolon or megaesophagus. Characteristically,
appears.
40% of patients with Chagas disease will develop impairment of
There are no clinical reports of the plague during pregnancy.
the cardiac conducting system, mainly left anterior hemiblock or
However, related Yersinia species, e.g. Y. pseudotuberculosis (the
anterior fascicular block. Clinical manifestations of gastrointest-
phylogenetic ancestor of Y. pestis) and Y. enterocolitica, can cause
inal tract denervation include constipation, gastroesophageal
abortion of the fetus in cows and sheep. Vaccines against the
reflux disease, and dysphagia.
plague are being explored.



333
5 Other disorders


The incidence of maternal transmission from patients in the meningitis, diffuse cerebral edema, brain abscesses, and epidural
chronic phase is 0.7%.218 Congenital disease occurs in 2“10% of abscesses.228,229 A fourteen-day course of chloramphenicol or
infants born to infected mothers,219,220 and may result in sponta- three-day course of ceftriaxone are both effective,230 along with
neous abortion, fetal hydrops, stillbirth, or birth of a premature supportive therapy. Since S. typhi can cross the placenta and lead
infant. Multiple maternal reinfections from repeated reduviid bug to neonatal infection, miscarriage, or fetal death, early treatment
bites increases maternal parasitemia and worsens congenital with ceftriaxone should be initiated. The possibility of CNS spread
Chagas disease.221 Diagnosis of congenital Chagas is by histologic of disease (meningitis, epidural, and cerebral abscess) limits the
evidence of placental villitis. There are no satisfactory drug thera- use of epidural and spinal anesthesia during the acute phase of the
pies to treat or to prevent transmission of the parasite to the disease. Abnormal liver function may mimic hemolysis, elevated
offspring. Patients who develop chronic Chagas disease tolerate liver enzymes, and low platelets (HELLP) syndrome.
regional anesthesia and GA without significant difficulties and Nontyphoid salmonella (S. enteritidis) has been reported to be
may complain of less postoperative pain than healthy patients. a cause of congenital infection leading to premature delivery and
neonatal death.231
However, a subset of patients will have a dilated cardiomyopathy
and potentially lethal ventricular dysrhythmias.222,223 The use of
etomidate and vecuronium for patients with cardiomyopathy has
Toxoplasmosis
been recommended.224
There are no specific obstetric anesthesia issues related to toxo-
plasmosis, except to note that congenital infections from vertical
Chlamydia psittaci (psittacosis)
transmission can lead to significant fetal and neonatal morbidity
Infection with Chlamydia psittaci leads to psittacosis, a pulmon- and mortality. Toxoplasma gondii is a cosmopolitan protozoan
ary and systemic disease that is contracted from inhalation of parasite of importance when occurring as a primary infection
dried psittacine bird (or sheep) excreta or handling of contami- during pregnancy and in the immunocompromised host (mainly
nated plumage. After replication in mononuclear phagocytes of HIV-positive mothers) due to the risk of transmission to the new-
the liver and spleen, C. psittacci spreads by the bloodstream to born. It is important that toxoplasmosis be prevented because
lungs and other organs. The incubation period varies from 5“14 even infants with untreated subclinical disease at birth have
days. Infection typically causes a mild influenza-like illness with developed seizures, significant cognitive and motor deficits, and
fever, chills, malaise, cough, mild pharyngitis, dyspnea, and diminution in cognitive function over time. Further, infants trea-
occasional pleuritic chest pain. Epistaxis, severe headache, and ted for a year with pyrimethamine and sulfadiazine still have
cognitive function that is less than their uninfected siblings.232
photophobia are common. A macular facial rash (Horder spots)
can occur in addition to erythema multiforme and erythema Pregnant women should avoid exposure to risk factors such as
nodosum.225 Psittacosis may be associated with endocarditis, raw or undercooked meat, unwashed fruits or vegetables, and cat
myocarditis, encephalitis, seizures, and focal neurologic lesions. excrement (especially in cat litter). As most cases of maternal
Disseminated intravascular coagulation can occur in advanced toxoplasmosis are asymptomatic, or marked only by nonspecific
cases. During pregnancy, psittacosis can present with severe lymphadenopathy, fever, or prostration, screening may be the
headache, atypical pneumonia (mainly dependent lobes) with only way to identify infection. Less common signs of disease in
hypoxemia, thrombocytopenia, anemia, hepatic dysfunction, the mother include myalgia, hepatitis, maculopapular lesions,
DIC, atypical pneumonia, and ARDS. Massive placental infection and pharyngitis, which may impair orotracheal intubation.
with impaired placental perfusion may lead to perinatal mortal-
ity. Premature birth is likely. The disease may culminate in death.
Leishmaniasis
Chest x-rays usually show patchy reticular infiltrates radiating out
from the hilum or involving basilar lung segments. Massive pla- Leishmaniasis can occur in two distinct forms, mucocutaneous
cental infection with impaired perfusion can ensue. Macrolide leishmaniasis and visceral leishmaniasis (kala-azar). Leishmania
antibiotics (doxycycline and tetracycline) are the drugs of choice panamensis, L. mexicana, L. tropica, and L. braziliensis are the
but due to adverse fetal effects (tooth discoloration), a trial of etiologic agents for mucocutaneous leishmaniasis. The mucocu-
erythromycin is preferred in pregnancy.226 With persistent dis- taneous form of leishmaniasis is usually self limiting. Destructive
ease, early delivery of the fetus may provide good maternal and lesions of the nasal, pharyngeal, and laryngeal mucosa can occur
fetal outcomes.226 in the advanced stages of the disease and may lead to mutilation
of the face and difficult endotracheal intubation.
Infection with L. chagasi, L. infantum, or L. donovani
Typhoid fever
results in visceral leishmaniasis (VL).233 This is a rare disease
Typhoid is predominantly a gastrointestinal gram-negative bac- and only anecdotal cases of VL in pregnancy have been reported.
terial disease caused by Salmonella typhi and S. paratyphi. The disease is life threatening for mothers and infants, is ende-
Ingestion of contaminated food is followed in 6“48 hours by mic in tropical and subtropical areas, and the possibility of ver-
tical transmission is real.233 Kala-azar disease is characterized
abdominal cramps, sustained bacteremia, high fever, vomiting
and diarrhea, and occasionally colonic perforation.227 There may by insidious fever, shivering, anorexia, nausea and vomiting, hepato-
be multiple organ dysfunction such as renal failure, hepatitis, splenomegaly, cutaneous lesions, anemia, and leukopenia. The



334
Chapter 18


complications.241 Extradural abscess can develop spontaneously
usual presentation in neonates with congenital disease is fever,
pancytopenia, and splenomegaly.234 Most antileishmanial drugs in in the postpartum period as described after GA.246 A dispropor-
use are reno- and cardio-toxic.233 The efficacy and safety of ampho- tionate number of extradural abscesses follow thoracic extradural
block, however.247 Patients taking concomitant systemic or extra-
tericin B for mother and fetus are supported by cumulative analysis
of the literature.235 dural steroids are at increased risk.248 Subdural empyema has
been described after spinal anesthesia.249
The most likely pathogen in spinal meningitis after regional
Q fever
anesthesia is Staphylococcus aureus, but 2.5% of CNS infections
Coxiella burnetti during pregnancy may manifest as acute pneu- have been attributed to Klebsiella pneumoniae. One case report
monia, hepatitis, or a flu-like illness. A severe chronic form exists, described an epidural infection secondary to cervical vertebra
osteomyelitis.250 Factors in the development of meningitis include
characterized by endocarditis, chronic hepatitis, and chronic
fatigue syndrome.236 The impact of Q fever on pregnancy is use of opioids,65,68 integrity of the immunologic system, bacterial/
unclear. A fetal death at 24 weeks™ gestation was reported in a viral count, and virulence in blood/CSF. Extradural abscess may
woman with chronic infection. The obstetrician who had contact have a variable presentation making diagnosis difficult. Early diag-
with the infected patient presented with pneumonia shortly after nosis should be considered in any patient who demonstrates signs
the fetal demise, perhaps as a result of aerosolization of organ- of infection, back pain, post-spinal headache, radicular pain, weak-
ness, paralysis, or bladder dysfunction.251 The incidence of spinal
isms from the infected placenta. The mother was treated with
co-trimoxazole and the obstetrician with doxycycline.237 epidural abscess is rising. Although increased awareness has led to
decreased mortality, morbidity remains unacceptably high, with
rapid deterioration of neurological status if there is delayed treat-
Viral hemorrhagic fever (VHF)
ment. Outcome is related to erythrocyte sedimentation rate, mus-
Four viruses cause VHF: Ebola, Lassa, Marburg, and Congo- cle strength at presentation, and speed of intervention. C-reactive
Crimean hemorrhagic fever viruses. Although the mode for noso- protein, comorbidities, age, sex, and degree of thecal sac compres-
comial transmission differs for each of these viruses, the limited sion have no prognostic value. The most important factors for good
data do not permit clear distinction.238 The mortality rate of the outcome in spinal epidural abscess include high clinical suspicion,
Ebola VHF is 79%. Frequent symptoms include fever (94%), diar- prompt investigation, and immediate intervention.
rhea (80%), and severe weakness (74%). Other symptoms include Patients with spinal epidural abscess may be normothermic and
dysphagia (41%) and hiccup (15%).239 The incubation period have normal white blood cell counts. Urgent surgery was more
ranges from two days to eight weeks, depending on the etiology. likely to be offered to patients presenting with neurologic deficits
The risk for person-to-person transmission of VHF is highest than with pain alone. Patients treated without early surgery were
significantly more likely to deteriorate and suffer poor outcomes.251
during the latter stages of illness, which are characterized by
vomiting, diarrhea, shock, and hemorrhage. Risk factors include In rats, dural puncture is associated with the development of
travel into specific local areas where VHF has occurred recently; meningitis, provided the animals are bacteremic at the time of the
direct contact with blood, feces, and contaminated needles and puncture. Antibiotic treatment before the puncture appears to
eliminate this risk.252 Antibiotic therapy appeared protective in
syringes; or contact with other body fluids from a person or
animal contaminated with VHF within eight weeks before onset eight bacteremic obstetric patients (seven had placental pathol-
of fever. The epidemic spread can also be due to familial trans- ogy consistent with chorioamnionitis) having regional anesthe-
mission. The local population™s superstitious interpretation of the sia, with none of the patients having infectious complications
such as epidural abscess or meningitis.253 However, there are
disease is a factor that must be taken into account during meet-
ings for behavioral change of the population.240 The virus can be reports of meningitis and epidural abscess after spinal anesthesia,
despite preoperative administration of antibiotics.254,255
detected by ELISA. Care must be taken in managing infected
people and body fluids, as recommended by the CDC. In the absence of guidelines, the anesthesiologist must con-
sider the risk for regional anesthesia versus GA individually, as no
risk is acceptable unless there is a clear benefit. For a localized
Anesthetic considerations in infectious diseases
infection away from the site of needle placement, the use of
extradural catheters appears to be relatively safe.253,256 For
There is no direct evidence that lumbar puncture, using proper
sterile technique, facilitates CNS disease by introducing viruses or patients with evidence of systemic infection, GA is recommended
bacteria from blood into the CSF. The incidence of meningitis in emergency situations. If intravascular volume has been opti-
after lumbar puncture appears to be similar to the incidence of mized, antibiotic therapy started, and the patient is responding to
spontaneous meningitis in bacteremic patients,241,242 although it therapy, regional anesthesia is acceptable.
is controversial.243 The incidence of extradural abscess after lum-
bar extradural catheterization in obstetric patients is estimated to
Conclusion
be 1 in 505 000,244 as opposed to the rate of spontaneous extra-
dural abscess formation in the general hospital population, which Many infectious diseases, especially those caused by emerging
is estimated to be 0.2“1.2 per 10 000.245 Hence, it may be difficult organisms, have sudden and devastating effects on the mother
to differentiate spontaneous from lumbar puncture-induced and fetus. In such cases, the role of the obstetric anesthesiologist



335
5 Other disorders



Appendix to Chapter 18 Classification of viruses infecting humans

Group Nature Virus (disease)

Poxviridae dsDNA, linear Smallpox virus, molluscum contagiosum virus
Herpesviridae dsDNA, linear Herpes simplex virus (chickenpox, shingles, zoster), cytomegalovirus (mononucleosis), Epstein
Barr virus (kissing disease), Kaposi™s sarcoma-associated herpesvirus
Adenoviridae dsDNA, linear Human adenovirus A to F (enteric infections, diarrhea, respiratory infections)
Papillomaviridae dsDNA, circular Papillomavirus (warts)
Polyomaviridae dsDNA, circular
Parvoviridae ssDNA, linear B19 virus (exanthema in children)
Hepadnaviridae dsDNA, circular Hepatitis B virus
Retroviridae ssDNA, (þ), linear Human immunodeficiency virus types 1 and 2
Reoviridae dsRNA, linear Reovirus (respiratory, enteric infections), rotavirus A and B (diarrhea, enteric infections)
Filoviridae ssRNA, (“), linear Ebola virus, Marburg virus
Paramyxoviridae ssRNA, linear Parainfluenza virus, mumps virus, measles virus, respiratory syncytial virus, hendravirus
Rhabdoviridae ssRNA, linear Rabies virus
Orthomyxoviridae ssRNA, (“), linear Influenza virus types A“C
Bunyaviridae ssRNA, (“), linear California encephalitis virus, Lit Crosse virus, Hantaan virus, Sin Nombre virus, Crimean-Congo
hemorrhagic fever virus
Arenaviridae ssRNA, (“), circular Lassa virus, lymphocytic choriomeningitis virus, Guanarito virus, Junin virus, Machupo virus,
Sabia virus
Coronaviridae ssRNA, (þ), linear Human coronavirus (respiratory and gastrointestinal infections)
Picornaviridae ssRNA, (þ), linear Human enterovirus types A“D, poliovirus, rhinovirus types A and B, hepatitis A virus,
parechovirus (human echovirus)
Caliciviridae ssRNA, (þ), linear Norwalk virus, Sapporo virus, hepatitis E virus
Astroviridae ssRNA, (þ), linear Human astrovirus (gastroenteric and enteric infections)
Togaviridae ssRNA, (þ), linear Ross River virus, Chikungunya virus, O™nyong-nyong virus, rubella virus
Flaviviridae ssRNA, (þ), linear Tick-borne encephalitis virus, dengue virus; Japanese encephalitis virus, Valley virus; St. Louis
encephalitis virus, West Nile virus, hepatitis C virus, hepatitis G virus, hepatitis GB virus,
Pestivirus, Hepacivirus
Deltavirus ssRNA, (“), circular Hepatitis deltavirus (aggravates hepatitis 13 virus infection)
Prions (no nucleic acid, self- Creutzteldt“Jakob disease, kuru, Gerstmann-Straussler-Schenker syndrome, fatal familial
replicating insomnia
infectious prion
protein)

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