This case study was approved by the relevant institutional review board and informed written consent was obtained from the patient for publication of this case report and accompanying images.
A 63-year-old man was admitted to the spine department with intractable back pain as the main symptom, and diagnosed with infectious spondylitis with discitis on MRI. He underwent more than three months of conservative treatment with antibiotics and orthosis in a local clinic. The patient had progressed to a collapsing disc space, and infectious spondylitis at the L3-4 level with an epidural abscess (Fig. 1).
Epidural abscess drainage through posterior decompression and morselized interbody bone graft with pedicle screw fixation was performed (Fig. 2). The first day after surgery, the patient presented with restlessness and disorientation without neurological symptoms. We consulted the psychiatric department and the patient was scheduled for oral medication. Thirty minutes later, the patient suddenly showed a mental change; he fell into a semi-comatose mental state without seizure-like activity and asphyxia. He was unresponsive to any voice or pain stimulation, except for voluntary lower extremity movement (hip, knee, and ankle contractions). The skin of the whole body was reddish and warm, but afebrile. The pupil light reflex was intact. Hemoglobin was 10.4 g/dL; blood pressure was approximately 108/67 mmHg; self-respiratory rate was 30-40 times per minute; heart rate, 120 beats/min. Oxygen saturation of 96% in room air. A finger-stick blood sugar level was 128 mg/dL. The intravenous parenteral fluid was normal saline.
We urgently consulted a neurologist and examined the emergent brain computed tomography (CT) and perfusion brain CT. There was no infarction or hemorrhage in the brain from the radiologic results, and we were informed that semi-comatose mentality was not the cause of brain disease. However, the neurologist did not rule out a silent seizure, and recommended aspirin and statin administration under Levine tube insertion. A lorazepam injection was performed due to suspected silent stroke and prevention of transient ischemic stroke. Arterial Boold Gas Analysis (ABGA) and laboratory results showed an increase in lactic acid, CK, and anion gap with a decrease in pCO2. As for the result of CK-MB, the possibility of cardiac origin was low. The respiratory rate was 30-40 times per minute in the state of compensatory hyperventilation due to lactic acidosis. Systolic blood pressure was maintained at around 100 mmHg, and urine output was below 50cc/Hr. However, there was a possibility of transition to a septic condition. An infection specialist recommended the prescription of cefazolin with vancomycin and ceftriaxone prior to obtaining the intraoperative culture results. The patient's inputs and outputs were monitored and balanced, as was ABGA, and frequently followed up. The patient's status was conferred to his family and we admitted him to the Surgical Intensive Care Unit (SICU) for observation.
The patient stabilized, and 10 h later started waking from the semi-comatose mental state. Upon regaining full consciousness, he stated that he had drunk half of a bottle of hand sanitizer (70% ethanol, 3 M Health care, St. Paul, MN) which had been placed at the foot of the bed to assist in the prevention of infection transmission during the COVID-19 pandemic. We confirmed the amount to be approximately 300-400 mL. The patient did not have a history of alcohol consumption or psychiatric medication and had no dependence. The blood alcohol level was slightly elevated at 100 mg/100 mL.
The patient complained of heartburn in the epigastric area; a gastroscopy was performed and a duodenal ulcer was diagnosed. He was treated for the ulcer with proton pump inhibitor medication, without gastric lavage. Delirium was controlled with haloperidol through psychiatric consultation.
After discharge, there were no adverse problems at the operation site of the infectious spondylitis. After seven months he had achieved complete bone union (Fig. 2), resolved the inflammatory reaction, and independent ambulation.