Disseminated methicillin-sensitive Staphylococcus aureus infection resulting from a paracervical abscess after acupuncture

A young woman was treated for musculoskeletal neck pain with acupuncture and developed a local paracervical abscess that progressed to a disseminated sepsis. The treatment was performed with an unusually long retention time of the acupuncture needle. This unique case shows that although acupuncture is deemed to be safe, serious complications may arise.

Clinical record

A 16-year-old, previously healthy girl was experiencing left-sided neck pain. She had no history of trauma or intravenous drug use, and there were no associated symptoms such as fevers, chills, cough or rigors. Initially, she attempted to manage her pain with simple pain medications. One week after onset, and experiencing ongoing pain, she presented to her general practitioner, who treated her with acupuncture. Two acupuncture needles (about 5 cm long) were placed locally to the left side of her neck. One remained for only 15 minutes; the other was fully inserted with only the handle visible and remained in situ for almost 24 hours.

Three days later, she developed significant worsening of her neck pain, lymphadenopathy, fevers, sweats and rigors. The next day, she was admitted at a small rural hospital with left neck pain and stiffness, associated with left-sided back and chest wall pain. She was started on 1 g of flucloxacillin every 6 hours.

Her pulse rate was 107 beats/min, oxygen saturation was 98% on room air, body temperature was 37.1°C and blood pressure was 121/68 mmHg. On physical examination, there was a diffuse swelling in the posterior triangle of her neck. An ejection systolic flow murmur was audible on auscultation. Oral candidiasis and pharyngitis with small punctate lesions were present. There was decreased air entry in her left lung base.

Investigations at the time of presentation showed a white blood cell count of 24.7 × 10⁹/L (reference interval [RI], 4–11 × 10⁹/L), C-reactive protein level of 404 mg/L (RI, < 10 mg/L) and albumin level of 17 mg/L (RI, 30–50 mg/L). Test results for HIV, hepatitis B and hepatitis C were negative. Blood cultures grew methicillin-sensitive Staphylococcus aureus. A chest x-ray showed a left pleural effusion. An ultrasound scan showed numerous enlarged lymph nodes in her neck that were reactive in appearance, as well as a left chest wall haematoma. A computed tomography (CT) scan of her neck also identified multiple small-volume reactive lymph nodes on both sides of the neck and diffuse subcutaneous oedema extending from the left preauricular region to the root of the neck. No focal fluid collection or abscess was identified. A CT scan of her chest and abdomen showed bilateral pleural effusions (left more than right), bilateral consolidation, splenomegaly, and a chest wall haematoma on the left.

A change of management involved increasing the flucloxacillin dose to 2 g every 4 hours (changed to 6-hourly on Day 10) and further investigations. On Day 1 after admission, a transthoracic echocardiogram showed no evidence of infective endocarditis. Her C-reactive protein level improved to 247 mg/L on Day 3.

A magnetic resonance imaging scan on Day 7 identified an infiltrative lesion in the posterior paravertebral muscles, involving cervical vertebrae 1–5 and the spinal canal at that level (Box). The diagnostic possibilities were primary or secondary malignancy or infection. A pleural tap the next day drained 500 mL of blood-stained fluid. Laboratory results confirmed an empyema that grew S. aureus from the tap fluid.

Eleven days after her admission to the rural hospital, she was transferred to our tertiary teaching hospital. A CT-guided biopsy of the lesion identified S. aureus infection. No monoclonal B-cell or aberrant T-cell or natural killer cell populations were detected. There was no need for surgical management. The patient improved significantly with antibiotic therapy and was discharged from the tertiary hospital after 10 days and transferred back to the rural hospital.

Discussion

Acupuncture is a common treatment used for the management of pain. It is an invasive procedure whereby a needle is inserted to varying depths below the skin. In a review of 12 prospective studies looking at more than one million treatments, there were 715 adverse events including 12 deaths.1,2 Serious complications included pneumothoraxes,1 infections and neurovascular injuries.3 A review of the literature identified 65 case reports and series of infection occurring after acupuncture. When there is a breakage in the protective skin, barrier infection is an expected complication. There are certain factors that increase the risk of an infection after acupuncture. These include inadequate skin disinfection and poor hygiene,4 the use of needles that are too long (with subsequent penetration of the bowel and direct inoculation of the soft tissues), patients with immunodeficiency,5 and acupuncture into joints that have a metal prosthesis.6 We believe that the time that the needle is kept in situ is likely to be another important factor in increasing the likelihood of developing infection.

There is only limited evidence for the advantage of prolonged acupuncture needle retention time and almost no evidence or recommendation for needle retention time for longer than a few hours.

Although some acupuncturists consider needle retention time as an important variable in the management of patients,7,8 there are limited studies examining the best needle retention time.7,8 Further, there are no randomised clinical trials demonstrating the efficacy of a needle retention time of 24 hours or more. Some studies found that increased needle retention time caused a greater duration of breach of the skin barrier, which could increase the likelihood of infection.9,10 The current infection control guidelines for acupuncture of the Australian Acupuncture and Chinese Medicine Association11 do not discuss the needle retention time.

Our patient’s left neck pain was thought to be musculoskeletal in origin and was initially managed with acupuncture by a GP. Both acupuncture needles were placed in the left neck region and one remained in situ for almost 24 hours. Because of the temporal nature of the cervical collection and the pain occurring in the exact location that the acupuncture needle was placed, the needle was the presumed source of infection.

This case shows a serious complication in an otherwise healthy young woman after an acupuncture treatment with unusually long needle retention time, which most likely contributed to the development of the infection. It highlights that even fairly minor invasive procedures can lead to significant complications. This should be considered when recommending these procedures, and high hygiene standards should always be applied.

Box –
Magnetic resonance imaging scan of the patient’s neck, showing a left-sided paracervical abscess (arrows)

[Correspondence] The World Bank under the leadership of Jim Kim

I read with interest the Special Report about Jim Kim by Sam Loewenberg (July 25, p 324).1 However, I thought a few points were missing. First, those who have taken up an executive position after working in a particular discipline, know how difficult it is to be fair to their own specialty of interest. For example, when Halfdan Mahler became Director-General of WHO in 1973, after many years of working in the specialty of tuberculosis, funding for tuberculosis was severely reduced. Similarly, when I became head of the Special Programme for Research and Training in Tropical Diseases in 1986, I reduced funding for my own specialty of leprosy.

Govts doing little to tackle climate health threat

More than half of governments around the world are yet to develop national plans to protect their citizens from the health effects of climate change despite increasing warnings it will cause more extreme weather, spread disease and put pressure on food and water supplies.

An international survey of 35 countries, including Australia, has found a general lack of focus and urgency around the looming threat of climate change to health, with most governments doing little work on likely effects and how to mitigate them.

The survey, coordinated by the World Federation of Public Health Associations (WFPHA), found that almost 80 per cent are yet to comprehensively assess the threat climate change poses to the health of their citizens, two-thirds had done little to identify vulnerable populations and infrastructure or examine their capacity to cope, and less than half had developed a national plan.

The result underlines the importance of repeated AMA calls for the Federal Government to do much more to prepare for the effects of climate change, which President Professor Brian Owler said were “inevitable”.

Earlier this year the AMA released an updated Position Statement on Climate Change and Human Health that warned of multiple risks including increasingly frequent and severe extreme weather events, deleterious effects on food production, increased pressure on scarce water resources, the displacement of people and an increase in health threats such as vector-borne diseases and climate-related illnesses.

“There are already significant health and social effects of climate change and extreme weather events, and these effects will worsen over time if we do not take action now,” Professor Owler said.

“Nations must start now to plan and prepare. If we do not get policies in place now, we will be doing the next generation a great disservice.

“It would be intergenerational theft of the worst kind — we would be robbing our kids of their future.”

In May, the AMA and the Australian Academy of Science jointly launched the Climate change challenges to health: Risks and opportunities report that detailed the likely health effects of climate change and called for the establishment of a National Centre of Disease Control to provide a national and coordinated approach to threat.

The WFPHA said the results of its survey, released little more than two weeks before the United Nations Climate Change Conference in Paris, should serve as a wake-up call for governments to do much more.

“The specifics of these responses provide insight into the lack of focus of national governments around the world on climate and health,” the Federation said.

Disturbingly, the survey found that Australia was one of the laggards in addressing the health effects of climate change, having done little to assess vulnerabilities and long-term impacts, develop an early warning system or adaptation responses, and yet to establish a health surveillance plan.

On many of these measures, the nation was lagging behind countries like the United States, Sweden, Taiwan, New Zealand and even Russia and China.

Climate and Health Alliance Executive Director Fiona Armstrong, who helped coordinate the survey, said the results showed the Federal Government needed to place far greater emphasis on human health in its approach to climate change.

“As a wealthy country…whose population is particularly vulnerable to the health impacts of climate change, it is very disappointing to see this lack of leadership from policymakers in Australia,” Ms Armstrong said.

Public Health Association of Australia Chief Executive Officer Mike Moore said the increasing number and ferocity of bushfires and storms underlined the urgent need for action.

“It is time to ensure that health-related climate issues are part of our national planning and budgeting if we are to pre-empt many avoidable illnesses and injuries,” Mr Moore said.

The AMA’s Position Statement on Climate Change and Human Health can be viewed at: position-statement/ama-position-statement-climate-change-and-human-health-2004-revised-2015

Adrian Rollins

Govt survey a smokescreen to undermine equal access: AMA

Charging smokers and the obese higher health insurance premiums is the first step toward a US-style system in which the poorest and sickest are shunted into over-stretched public health services while insurers book big profits, AMA President Professor Brian Owler has warned.

Professor Owler has launched a full-blooded attack on the Federal Government over a survey it has launched which asks consumers whether they think insurers should be given the discretion to charge different premiums according to smoking habits, obesity and other health risks.

The AMA President said the Government’s move played into the hands of health funds keen to offload customers with serious and chronic illnesses onto the public system in order to boost their profits, and would do nothing to cut down on smoking or otherwise improve health.

“We all know that non-smokers are going to say ‘Yes, I want to pay less for my premiums,” the AMA President said. “This is not the way to tackle smoking.”

He said the bigger policy question was whether people were prepared to let health funds pick and choose who they insured, taking into account that procedures like genetic screening for potentially fatal diseases would soon be a reality.

“If you’re positive for a genetic test, are you going to be denied cover? These are the sorts of questions that we need to be asking,” Professor Owler said.

Health Minister Sussan Ley seized on figures showing health insurance policies covering 500,000 people were dumped or downgraded in 2014-15 to argue insurers need to provide much better value.

Ms Ley said the Government was committed to “recalibrating” the private health system to make it value for money following a succession of premium increases that have outstripped inflation and the proliferation of junk policies that offer nothing more than a public hospital bed.

“Consumers are angry, confused, and I’m concerned that simply shopping around is no longer enough to get the best value for money,” she said, inviting them to take part in an online survey being run by the Health Department.

Premium increases outstrip costs

The private health insurance market is dominated by five big funds and the industry recorded an after-tax profit of $1.1 billion in 2014-15. Premium revenue surged by 7.3 per cent, leading the regulator to note that “the increasing cost of health services and growing utilisation rates have been more than offset by higher premiums”.

But the Minister has been forced on to the defensive amid criticism that her approach to put the interests of insurers ahead of patients, particularly the sickest and most vulnerable.

Shadow Health Minister Catherine King said suggestions in the survey that insurers be allowed to charge different premiums according to age and gender as well as lifestyle habits like smoking showed that women and the elderly were in the Government’s sights.

Ms King said it was alarming that the survey highlighted the higher benefits paid out to patients 75 years or older, while asking about gender was a “clear sign” that women of child bearing age would be required to pay higher premiums.

Community rating under attack

Professor Owler said the private funds wanted to undermine community rating, the principle under which insurers must offer the same price of health cover to all, regardless of their health risk, in order to boost their bottom line.

This was the intention behind the push to have smokers charged a higher premium, he said, warning the idea would eventually be extended to policyholders with other health risks.

“Where does it stop, because we know that genetic testing is coming down the track. You know that obesity and all sorts of other issues are going to be brought into play in the future, and…the insurers are only going to want to insure those people that are fit and healthy and don’t need anything done to them,” Professor Owler said. “That is all about maintaining their bottom line and…improving their margins.”

His concerns were given added weight when Mark Fitzgibbon, Chief Executive of insurer NIB, told Fairfax Media that although higher premiums for smokers would be the first move, insurers might eventually monitor the habits of policyholders to reward healthy behaviour like exercise (and, by implication, to punish unhealthy activity).

But Ms Ley said it was not the Government’s intention to impair access to health care, and its starting point was that Medicare and public hospital system remain universally accessible.

“It’s important we’re able to ask consumers what they expect from their private health insurance, and there’s plenty of room to do that without moving towards US or UK models that exclude sick people, or make it only available to rich people, which we don’t support,” she said.

But the Minister flagged changes to industry regulation, remarking that a succession of the above-inflation premium increases suggested there was “something wrong” with its regulatory foundations.

Professor Owler said this was worrying.

“I find it very concerning when the Health Minister makes statements like she’s concerned that the health insurers are wrapped up in regulation or being restricted by regulation,” he said. “Those regulations are there to protect the public health system, and they’re there for a good reason.”

Adrian Rollins

Latest news:

[Editorial] Advancing China’s health and medical science

The Lancet and the Chinese Academy of Medical Sciences (CAMS) held the first of what will become their annual Health Summit in Beijing last week. More than 500 delegates, most from China, participated. 30 research abstracts were selected from among 600 submissions for oral presentation, together with around 100 posters. Four keynote speeches highlighted critical aspects of China’s endeavour to achieve universal health coverage by 2020: Nanshan Zhong spoke about the continuing threat of air pollution and chronic airway diseases; Wang Yu described the neglected challenge of hepatitis B and C; Richard Peto set out a comprehensive strategy to halve premature mortality; and Xuetao Cao presented a manifesto for strengthening the scientific capacity of China to meet the needs of its 1·3 billion people.

[Comment] A Commission on obesity

The global pandemic of obesity continues unabated: 2·7 billion adults are projected to be overweight or have obesity by 2025.1 Obesity is driving global increases in type 2 diabetes, cardiovascular diseases, and several types of cancer, yet the implementation of recommended policies to reduce obesity has been slow and patchy.2 Therefore, WHO targets for 20253 to “halt the rise of obesity and diabetes” from the 2010 baseline will not be met without major global action. In addition, obesity is a visible marker of serious, underlying, systemic problems in food systems and in urban design and transport systems.

[Comment] Respiratory medicine and critical care: a call for papers

As health care becomes ever more complex and the approach to treatment more personalised, research is a vital component in our mission to help improve the lives of patients living with respiratory diseases. From understanding the genetic links to disease to cutting-edge treatments, high-quality research helps us to navigate the intricate path to optimum care for patients.

Freedom of choice a weighty problem

Governments will have little choice but to tighten food and marketing regulations and possibly increase taxes on unhealthy products if the nation’s waistline continues to bulge, the AMA has warned.

The peak medical representative organisation told a Senate inquiry into so-called “nanny state” laws that unless Australians improved their diets and increased physical activity, rates of overweight and obesity would continue to climb and the consequent social and economic costs could force governments to act.

While not calling for a sugar tax, the AMA warned that simply giving people information for them to make informed choices may not, by itself, be enough.

“If people continue to make poor choices, and the number of adults who are overweight or obese continues to increase, Government will have little choice but to regulate,” it said, suggesting this might extend to include “restricting…advertising, increasing price, and reducing access, to products known to have a negative impact on health”.

Its views were echoed by ACT Chief Health Officer Dr Paul Kelly, who told The Canberra Times that although he did not advocate a sugar tax, government needed to be “part of the solution” to obesity.

“Just telling people [about healthy food choices], and asking them to make their own decision, is insufficient,” Dr Kelly said. “We know that the majority of the work we do in the hospital system is related to chronic diseases, many of which, if not caused by, are at least made worse by people being overweight or obese. And that’s a real cost to the whole community.”

The AMA made its warning in a submission to the Senate inquiry being led by Liberal Democratic Party Senator David Leyonhjelm, who objects to what he sees as unwarranted Government constraints on freedom of choice, and has taken particular aim at public health measures such as tobacco controls, alcohol restrictions and bicycle helmet laws.

“It’s not the government’s business, unless you are likely to harm another person. Harming yourself is your business, but it’s not the government’s business,” Senator Leyonhjelm said. “So bicycle helmets, for example, it’s not a threat to other people if you don’t wear a helmet; you’re not going to bang your bare head into someone else.”

Poor choices can hurt many

But the AMA argued this was a narrow view that ignored the society-wide consequences of individual choices.

The Association said that often people failed to appreciate the effect of their choices on those around them.

“All too often it is family members and governments who are left to provide support and care for poor individual decision-making,” the AMA said. “More tragically, sometimes innocent victims have to bear the consequences. As doctors, we see too many innocent victims, victims of road traffic accidents caused by drunk or speeding drivers, victims of alcohol and drug-induced violence.”

The Association said that millions were alive today because of public health initiatives such as vaccination programs, road safety laws, smoking restrictions and air and water standards that initially encountered resistance, but which are now widely accepted and supported as reducing the risk to individuals and enhancing the common good.

For example, smoking is a leading cause of preventable deaths, and dealing with its health and economic consequences costs the country billions of dollars each year. For this reason, the community accepts and expects measures to control tobacco marketing and use.

Similarly, compulsory bicycle helmets laws introduced in the early 1990s have been found to have greatly reduced the risk of head injury for cyclists, to the benefit of individuals, their families and the community.

Sydney University philosopher Professor Paul Griffiths and Sydney Law School Professor Roger Magnusson said Senator Leyonhjelm’s critique of public health measures missed the mark.

“Australia’s health legislation is a poor candidate for Libertarian criticism,” they wrote in The Age. “Accurate information about the risks and harms posed by consumer products increases freedom by helping people understand their options.”

In its submission, the AMA rejected the view that these and similar regulations were an unwarranted intrusion on individual liberty.

It said that even with such public health measures in place, “people in Australia are largely able to do as they wish, even when it is likely to cause harm to themselves or others – some people continue to smoke or consumer excessive amounts of alcohol”.

But the AMA asserted governments had a responsibility to protect people from harm caused by others, and to regulate behaviour to improve individual health and promote the greater good.

“Government does have a role to play in making this country a safer and healthier society,” it argued, “…in regulating and modifying the behaviour of individuals so that the rest of us can be confident that we won’t be affected by the poor decisions of others, such as being run off the road by a drunk driver.”

“We need all those who have a responsibility for prevention, including governments at all levels, to live up to their responsibilities for public health and prevention.”

Adrian Rollins

Post-artesunate delayed haemolysis in severe imported Plasmodium falciparum malaria

We report a case of post-artesunate delayed haemolysis (PADH) in severe Plasmodium falciparum malaria.

A female wildlife conservation worker based in South Africa presented with severe malaria (hypotensive shock and 30% parasitaemia level). She had not been on malaria prophylaxis. Six months earlier she had a febrile illness after a tick bite, which was treated with doxycycline with complete resolution. Blood tests revealed renal impairment, abnormal liver function tests with coagulopathy and thrombocytopenia without intravascular haemolysis. Systemic examination was unremarkable.

In the intensive care unit she was given intravenous artesunate for 5 days and supportive platelet transfusion. Blood cultures and serologies for dengue, leptospirosis, schistosomiasis, rickettsia and HIV were negative. Oral artemether-lumefantrine was prescribed to complete malaria treatment. Recurrence of haemolysis was observed on Day 10 of admission (1 week after artesunate treatment). Extravascular haemolysis was confirmed by low haptoglobin and elevated lactate dehydrogenase (LDH) levels. Other causes of haemolysis such as viral haemorrhagic fever (Rift Valley and Crimean–Congo fevers), drugs and viral infections were excluded.

A literature search of haemolytic causes alluded to the possibility of PADH.1 Proposed criteria by the United States Centers for Disease Control and Prevention (CDC) for PADH (a decline in haemoglobin levels of ≥ 10%, haptoglobin levels of ≤ 0.1 g/L and an increase in LDH levels of > 390 U/L) were present.1 Supportive therapy with blood transfusion led to restabilisation of haemoglobin. Convalescent serological testing found an increase in Rickettsia typhi titre from < 128 to 256 before discharge. This was consistent with murine typhus likely caused by flea bites when cleaning her room. Empirical therapy with doxycycline given earlier in the current admission would have treated this.

Artesunate is the drug of choice to treat severe P. falciparum infection due to concerns of drug resistance and mortality benefit.2 PADH is a rare but significant complication of artesunate, with 23 confirmed and 15 probable cases.3 Although there has been heterogeneity in the criteria for diagnosis of PADH in the past, the CDC optimised the definition in 2014.1,4 PADH typically occurs 1 to 3 weeks after administration of intravenous artesunate treatment.1 Artesunate supplied in Australia is manufactured overseas (China) and sourced by a local company. Although controversy remains around artesunate manufactured overseas due to non-adherence to Good Manufacturing Practice (GMP) guidelines, whether PADH is caused by direct toxicity from the drug in non-GMP settings remains speculative as it has also been described in three patients who received the drug made in the US and Canada.4,5 There are two proposed mechanisms of PADH: (i) rapid clearance of parasite from the infected red blood cells causes them to “pit”, which causes haemolysis; and (ii) activation of the pro-inflammatory cytokines.3,4 Higher parasitaemia levels in non-immune patients are more frequently associated with PADH.1,4 PADH is also known to occur with oral artemisinin derivatives.1

Clinicians using artesunate to treat patients diagnosed with falciparum malaria need to be aware of the risk of PADH, especially if haemolysis develops after treatment. Based on the current literature, we recommend a follow-up of at least 1 month after treatment.1,2

[Comment] Long working hours: an avoidable cause of stroke?

William Osler, in an article about atherosclerosis published 100 years ago, wrote that the main cause of myocardial infarction was “wear and tear of life”.1 Although we now have more detailed theories regarding the causal mechanisms, there is still some kinship between modern studies of work-related determinants of cardiovascular diseases and Osler’s broad approach to the cause of disease.2