Diabetic Ketoacidosis Precipitated by Staphylococcus au...

Diabetic Ketoacidosis Precipitated by Staphylococcus aureus Abscess and Bacteremia Due to Acupuncture: Case Report and Review of the Literature

Clinical Infectious Diseases 2006;43:e6Òe8
© 2006 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2006/4301-00E2$15.00
DOI: 10.1086/504945

BRIEF REPORT

Diabetic Ketoacidosis Precipitated by Staphylococcus aureus Abscess and Bacteremia Due to Acupuncture: Case Report and Review of the Literature

Eric J. Seeley and Henry F. Chambers

Department of Internal Medicine, University of California, San Francisco

Acupuncture use is increasing in the United States. Despite multiple studies, the efficacy and safety of acupuncture are poorly defined. We report a previously healthy patient who developed a thigh abscess, bacteremia, and diabetic ketoacidosis after acupuncture treatment. We review the literature on infectious complications of acupuncture.

Received 13 December 2005; accepted 8 March 2006; electronically published 23 May 2006.
Reprints or correpsondence: Dr. Eric J. Seeley, UCSF Dept. of Internal Medicine, 4150 Clement St., San Francisco, CA 94121 (eseeley@itsa.ucsf.edu).

Case report. A 31-year-old, healthy Asian man presented to the emergency department with right thigh pain, shortness of breath, nausea, and vomiting. A week before admission, he reported straining his right thigh and gluteal muscles while lifting weights. Three days before admission, the patient went to a traditional Chinese doctor and received acupuncture for persistent right hip pain. Needles were inserted into his right hip and thigh, and the patient experienced mild relief from pain. An iodine-based antiseptic was used; however, the details of the acupuncturist's sterile techniques were unknown. Three days later, the patient developed progressive, painful right thigh swelling, as well as polydipsia, polyuria, and tachypnea. He presented to the hospital on the following day.

At hospital admission, the patient was afebrile. His blood pressure was 134/73 mm Hg, his heart rate was 142 beats per minute, his respiratory rate was 44 breaths per minute, and his oxygen saturation was 98% in room air. He appeared uncomfortable and was using accessory muscles to breathe. His heart was tachycardic and regular without any murmurs. His right thigh was enlarged and tender to palpation. He had pain with active and passive hip flexion. His distal pulses were equal and bounding, and the rest of his examination findings were unremarkable. His laboratory values were notable for a WBC count of 23,000 cells/&#956;L, an undetectable bicarbonate level (<5 mmol/L), an anion gap level of >32 mmol/L, a glucose level of 727 mg/dL, and a creatinine level of 2.1 mg/dL. The patient was admitted to the hospital and treated with intravenous hydration and insulin, and his acidosis and hyperglycemia resolved without complication.

On hospital day 2, the patient developed a fever. Cultures of 2 of 2 peripheral blood samples grew methicillin-susceptible Staphylococcus aureus within 18 h. Because of progressive thigh pain and swelling, a contrast-enhanced CT scan of his right thigh was performed, revealing a rim-enhancing mass in the right obturator externus and adductor muscles consistent with abscess (figure 1). Percutaneous catheter drainage of the cavity under ultrasound guidance produced purulent fluid that also grew S. aureus with the same susceptibility as the blood isolate.
Figure thumbnailFigure 1. (199 KB)

Figure 1. Contrast-enhanced CT scan of the right thigh showing a abscess in the obturator externus and adductor muscles. The arrow shows rim enhancement of the anterior edge of the abscess.

The patient was initially treated with vancomycin (1 g intravenously every 12 h) followed by nafcillin (1.5 g intravenously every 4 h) after results of the culture were returned. The patient's fever resolved, and he was discharged home on the eighth hospital day with a 4-week course of amoxicillin-clavulanate (750 mg orally twice per day).

Discussion. Acupuncture has become a widely practiced and accepted component of complementary and alternative medicine. Its use has grown during the past decade and will likely continue to increase. As an alternative form of medicine, with a 5000-year history in China, many patients believe this treatment to be safe and effective. However, prospective studies on its safety and efficacy are lacking. There are >715 case reports linking acupuncture to adverse outcomes, including mechanical injury and infection [1].

Mechanical injuries range from benign to lethal. There are >90 reports of pneumothorax, the most commonly reported mechanical injury, including 2 cases of lethal tension pneumothorax [2]. In 1 series from Japan, 9% of pneumothoracies seen in an emergency department case series were caused by acupuncture [2]. There are 6 reports of cardiac tamponade, 2 of which were fatal. There are >10 case reports of spinal cord or nerve damage and several reports of spinal subarachnoid hemorrhage.

Infectious complications due to acupuncture are difficult to prove; however, multiple reports describe transmission of viral and bacterial pathogens. Hepatitis B virus is the best-documented viral pathogen spread by acupuncture. In a review published in 1995, Rampes and James [3] identified 126 cases of hepatitis B due to acupuncture. Hepatitis B due to the reuse of hollow needles was described in a case series of 36 patients in the United Kingdom [5]. Several outbreaks have been described in the United States as well, with 35 patients in Rhode Island and 6 patients in Florida whose cases of hepatitis B were linked to acupuncture [5].

Epidemiologic data support acupuncture as an independent risk factor for hepatitis C infection. Kiyosawa et al. [6] investigated 2 populations in Japan: one that lived in an area of endemicity for hepatitis C (prevalence of infection, 32%); the other had a low prevalence of infection (2.3%). There was a high correlation between the use of acupuncture and cupping and the risk of hepatitis C in the population where hepatitis C was endemic. A second study in Japan investigated the cause of hepatitis C in 149 asymptomatic patients identified in routine screening of donated blood. A history of blood transfusion was the risk factor in one-third of cases. However, in 20% of cases, a history of acupuncture was the only identifiable risk factor [7].

Acupuncture has been implicated in the spread of HIV as well. The viral inoculum needed to transmit HIV is larger than that needed to spread hepatitis viruses B and C. Thus, it is not surprising that there are fewer reported cases of HIV transmission. In a report from France, a man developed a febrile illness the week after completing a 6-week course of acupuncture. Eight weeks later, he became HIV positive, and no other risks factors were identified [4]. In a report from Thailand, a 60-year-old woman without a history of injection drug use or blood transfusion and without tattoos who had not had sexual contact for 20 years was determined to be HIV positive during a routine health screening. Her only risk factor was frequent acupuncture from a Chinese acupuncturist who reused needles without sterilization and who treated patients with HIV infection [8]. In a case series of 148 patients with HIV infection, 2 patients who had no known risk factors had received acupuncture in the interval before their seroconversion [4]. These case reports are correlative; nonetheless, they suggest that acupuncture, when applied with reused needles, poses more than theoretical risk for HIV transmission.

The most common bacterial infection due to acupuncture is local cellulitis at the site of needle insertion [9]. However, serious infections, such as endocarditis, spinal epidural abscesses, necrotizing fasciitis [10], and sepsis have been reported. The most common pathogen in 1 case series was S. aureus (9 [56%] of 16 patients had S. aureus infection), and there are 2 case reports of death due to staphylococcal sepsis in the literature [4]. Other reported organisms include Pseudomonas aeruginosa, streptococcal species, Propionbacterium acnes, and Mycobacterium chelonae. Many of these infections occurred in patients with diabetes who mount diminished healing and immune responses to disruption of their epidermal barrier. There are no case reports of acupuncture-related infection precipitating diabetic ketoacidosis. Other risk factors for serious bacterial infections following acupuncture include duration of needle insertion, the presence of diseased or prosthetic heart valves, and immunosuppression.

The incidence of acupuncture-related adverse outcomes is not well defined. Because of the increased interest in acupuncture, several prospective population-based studies have been conducted. Many of these studies, although prospective and large, are flawed, because they have relied on self-reported data from acupuncture practitioners. Prospective data reported by physicians who also practice acupuncture may underestimate the complication rate for nonphysician practitioners, because physicians may be less likely to cause adverse outcomes because of their knowledge of infection control and anatomy.

Three recent prospective studies on the safety of acupuncture report low rates of complication. In Britain, White et al. [11] observed 78 physicians and physiotherapists practicing acupuncture for >30,000 consultations during a 2-year period. Forty-three significant incidents were self reported, yielding a rate of 14 incidents per 10,000 consultations; in other words, 0.14% of consultations resulted in significant incidents. No serious events as defined by the study were reported, and the only infectious complication was local cellulitis. In the York acupuncture safety study [12], a 4-week survey of self-reported adverse events by 574 practitioners during >34,000 consultations, no serious adverse events were reported. Minor events, including nausea, dizziness, bruising, and bleeding, occurred in 0.13% of consultations. Melchart et al. [13] reported a prospective investigation of acupuncture in Germany, during which 7000 physician acupuncturists reported events on nearly 100,000 patients. Six serious reactions were reported: 2 pneumothoracies, 1 asthma attack, 1 vasovagal reaction, and 1 acute hypertensive crisis.

As acupuncture becomes increasingly popular, it is important for patients to understand its risks and benefits. The risk of serious complications due to acupuncture is probably lowÛperhaps <1 in 10,000 treatments. Nonetheless, the evidence for acupuncture as a successful treatment for all but a few conditions is equivocal. Thus, patients and practitioners must assess the risk benefit ratio of therapy. Specifically, patients with diabetes who are immunosuppressed or who have valvular heart disease may be at increased risk of serious infection due to acupuncture. Furthermore, patients should ensure that their practitioners are licensed and employ single-use sterile needles.
Acknowledgments
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We thank Dr., Brad Jacobs for his insightful comments on the manuscript.

Potential conflicts of interest. E.J.S. and H.F.C.: no conflicts.
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(2008) Pneumothorax and pleural empyema after acupuncture. Internal Medicine Journal 38:8, 678-680
Online publication date: 1-Sep-2008.
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