後頸部へのトリガーポイント注射後に細菌性髄膜炎，化膿性血栓性静脈炎を発症した1例

Bacterial Meningitis and Suppurative Thrombophlebitis after Trigger Point Injections: A Case Report

症例は未治療糖尿病がある73歳女性。運動後の右肩痛に対して胸鎖乳突筋と僧帽筋にトリガーポイント注射を受けた後から，発熱と頭痛が出現した。脳脊髄液検査で多形核球優位の細胞数上昇，蛋白上昇および糖の低下，頸部造影MRIでは右後頸筋〜C5，C6レベルの右椎弓や椎間孔に広範な炎症所見を認め，後頸部の静脈には造影欠損が見られた。細菌性髄膜炎，化膿性血栓性静脈炎として広域抗菌薬を開始すると症状はすみやかに改善し無症状で自宅退院した。トリガーポイント注射は安全な手技として汎用されるが，稀に中枢神経感染症を合併し得ることは知っておくべきと考えたため報告する。

Abstract

A 73-year-old woman with untreated diabetes mellitus visited our emergency department with a 4-day history of progressive headache, fever, and chills. She received trigger point injections (TPI) into the right sternocleidomastoid for exercise-induced ipsilateral shoulder pain, 13 days before admission and into the right trapezius, 6 days before admission. Cerebrospinal fluid (CSF) evaluation revealed pleocytosis with a predominance of neutrophils, as well as elevated protein and reduced glucose levels. Magnetic resonance imaging of the cervical spine revealed inflammatory changes of the right-sided posterior cervical muscles and the right vertebral arch of the C5-C6 vertebrae without contrast enhancement of the right posterior cervical veins. She was diagnosed with bacterial meningitis and suppurative thrombophlebitis, and empiric broad-spectrum antibiotic therapy was administered intravenously. The initial blood culture yielded Streptococcus intermedius; however, CSF culture showed no growth. She recovered completely after a 4-week course of intravenously administered ampicillin and was discharged with oral clindamycin to complete a total 6-week antibiotic course. TPI are widely used as a safe therapeutic strategy associated with few complications, and serious infections are rare. However, clinicians must remain mindful of the possibility of these complications in immunocompromised patients, such as those with diabetes mellitus who undergo TPI.

(Received September 18, 2020; Accepted December 21, 2020; Published June 1, 2021)