Clinical problem-solving. Beware of first impressions

A 64-year-old Filipino man presented to a Baltimore hospital with a 4-month history of worsening midback pain, progressive leg weakness, and intermittent bladder and bowel incontinence. He had no fever or pulmonary symptoms. Magnetic resonance imaging (MRI) of the thoracic spine revealed hypointense T₁-weighted and hyperintense T₂-weighted bone marrow signal involving vertebral bodies T2, T3, and T4 (findings that were consistent with osteomyelitis); vertebral compression fractures; an epidural fluid collection; and spinal cord compression (Fig. 1). Multiple blood cultures were negative. Because the spine was considered unstable, he underwent T2, T3, and T4 vertebrectomy with fusion from C3 to T8. Pathological studies of the operative specimen revealed granulation and chronic inflammation. No organisms were identified with the use of routine or special stains, including an auramine– phenol stain for acid-fast bacilli. Vertebral bone and material from the fluid collection were sent for fungal, mycobacterial, and routine bacterial cultures before the initiation of treatment with antimicrobial agents.

Cervical vertebral osteomyelitis and epidural abscess caused by Candida albicans in a patient with chronic renal failure

Although rare, the diagnosis of candidal vertebral osteomyelitis of the cervical spine should be considered in cases of quadriparesia occurring in hemodialysis patients. This disease leads to vertebral destruction and spinal cord compression. Candidal vertebral osteomyelitis constitutes a diagnostic problem for all physicians. The insidious progression of disease, the non-specificity of the clinic and laboratory findings, and the failure to recognize candida as a potential pathogen may lead to a diagnostic delay. Early diagnosis and treatment are fundamental points for prognosis. In this report, we present the fifth case of cervical vertebral osteomyelitis caused by Candida species in the literature. Our case is the second case of candidal vertebral osteomyelitis associated with epidural abscess of the cervical spine.

A rare cause of "foot drop": spinal epidural brucella granuloma

Spinal epidural abscess is rare but serious medical condition which may cause permanent neurological deficits, or even death, if not treated. Staphylococcus aureus is the responsible microorganism in most spinal abscess cases. However, rarely other microorganisms like Brucella may be responsible. Brucellosis, a zoonotic infection endemic in the Mediterranean Region, Middle East; and South and Central America, most frequently involves the reticuloendothelial and musculoskeletal systems. Vertebral involvement is rarely seen; and its differential diagnosis is rather difficult. Spondylodiscitis and rarely spinal abscess or development of a granuloma are the main pathologies. Spinal epidural granulomas due to brucellosis may cause neurologic deficits. In this case presentation, a spinal epidural brucella granuloma causing foot drop is discussed taking other reports into account.

The vein of Labbe masquerading as an epidural abscess

The occipitotemporal vein (OTV) courses over the temporal lobe, connecting the superficial middle cerebral vein and the transverse sinus. This vein is rarely identifiable on computerized tomography (CT) scans and a large amount of contrast is needed to identify such a relatively small vessel. We present a 12-month-old male with acute coalescent mastoiditis and a subperiosteal abscess. An epidural abscess was suspected on pre-operative CT scan. No abscess was found on surgery. Based on the surgical finding, we determined that this misdiagnosis was due to a vascular variant, the occipitotemporal vein (vein of Labbe) that masqueraded as an abcess on the CT scan. Recognition of the vein of Labbe on CT scan is therefore essential for the appropriate management of otological and neurotological disease.

A less invasive posterior approach for the management of extended secondary epidural abscess technical note

Spondylodiscitis is considered to be the main cause of epidural abscess. In this report, the authors present their concept for the management of the extended epidural abscess that occurs in combination with spondylodiscitis. It consists of debridement and fusion for spondylodiscitis together with epidural abscess drainage using a microscopically assisted percutaneous technique. In the period from April 2000 to April 2004, 5 patients with spondylodiscitis and an accompanying extended epidural abscess were operated on. The mean age of the patients was 66 years. There were 4 males and one female. The follow-up period ranged from 3-12 months. To manage the extended epidural abscess, the authors created one or two drainage sites along the extension of epidural abscess. These drainage sites were made using a microscopically assisted percutaneous approach. In all presented cases, the offending organism was Staphylococcus aureus. The postoperative infection markers showed marked regression. The postoperative control MRI demonstrated effective drainage of the extended epidural abscess. Regarding the neurological deficits, 3 patients previously classified as Frankel C showed an improvement to Frankel E within 3 months postoperatively. From these results, it seems that our technique (ventro-dorsal abscess drainage combined with a microscopically assisted percutaneous approach) could be a successful method for the management of the extended epidural abscess associated with spondylodiscitis.

ACUTE CENTRAL CORD SYNDROME ARISING FROM A CERVICAL EPIDURAL ABSCESS

OBJECTIVE

Acute central cord syndrome (ACCS) is a well-known sequela to spinal trauma but has rarely been associated with nontraumatic etiologies. Spinal epidural abscess (SEA) and spinal osteomyelitis/discitis are also well characterized clinical entities. Neither SEA nor osteomyelitis leading to ACCS has been previously reported.

CLINICAL PRESENTATION

In this report, a patient presented with refractory neck pain after minor trauma followed by development of left hand weakness and paresthesia, which progressed to a classic central cord injury clinical pattern over a period of 4 weeks.

INTERVENTION

Imaging and laboratory studies were consistent with SEA and osteomyelitis. Motor evoked potentials obtained during surgery definitively corroborated the clinical diagnosis of ACCS and supported a long tract pathophysiology.

CONCLUSION

ACCS may be caused by SEA.

The incidence of spontaneous epidural abscess in Olmsted County from 1990 through 2000: a rare cause of spinal pain

OBJECTIVE

The primary objective of this study is to determine the population-based incidence of spontaneous epidural abscess. The secondary objective is to characterize the clinical course of patients with this rare infectious disease.

DESIGN

The records-linkage system of the Rochester Epidemiology Project was used to identify incident cases of spontaneous epidural abscess in residents of Olmsted County, Minnesota, USA, from 1990 through 2000.

SETTING

Tertiary referral medical center.

PATIENTS

All patients were residents of Olmsted County and had spontaneous epidural abscesses that were radiographically or surgically confirmed.

RESULTS

Eight patients, including six women, were identified and the mean age was 56 years (range, 40-80). The incidence of epidural abscess was 0.88 cases per 100,000 person-years (95% confidence interval, 0.27-1.48). The median time from symptom onset to diagnosis was 18 days (interquartile range, 4-30 days). Six patients presented with spinal pain and one presented with focal neurological deficits. Risk factors were identified in all patients, including concomitant infections, diabetes mellitus, immunosuppression, and intravenous substance abuse. Staphylococcus aureus was cultured in six patients and streptococcal species were cultured in two patients. Three patients were treated surgically and five received medical treatment. One patient treated surgically and one patient treated medically had residual neurological deficits. One patient, who was immunosuppressed and received medical treatment died of pneumonia.

CONCLUSIONS

This is the first published report of the population-based incidence of spontaneous epidural abscess. These findings could serve as a reference point for further epidemiological research related to this uncommon infection.

Acute orbital complications of sinusitis: the benefits of magnetic resonance imaging

Introduction:

Acute sinusitis is a relatively common condition, which usually responds to medical therapy. In most cases, there are no sequelae or complications subsequent to this infection. However, like many acute illnesses, there are well documented complications of acute sinusitis, and in particular these include peri-orbital and intracranial spread.

Objective:

The purpose of this paper is to highlight the importance of vigilance regarding both peri-orbital involvement of sinusitis and the limitations of imaging techniques such as computed tomography. An illustrative case is presented to demonstrate this.

Conclusion:

Magnetic resonance imaging is a valuable modality in assessing complex presentations of peri-orbital complications of acute sinusitis.

Bilateral Eyelid Edema and Orbital Cellulitis Associated With Pott's Puffy Tumor

Pott's puffy tumor is rarely associated with orbital cellulitis. We describe a pediatric patient with Pott's puffy tumor and right-sided orbital cellulitis. He underwent urgent surgical drainage of a glabellar subperiosteal abscess and completed a six week course of intravenous antibiotics with complete resolution of infection and no long-term sequelae. Close monitoring with imaging for intracranial spread and multidisciplinary surgical intervention are commonly recommended.

[Syrinx formation secondary to cervical epidural abscess]

We report a patient with syrinx formation secondary to cervical epidural abscess, cervical spondylitis, cervical discitis and meningitis. A 53-year-old woman developed sudden fever, headache and neck pain. On admission, neurological evaluation showed limitation of cervical motion, meningeal irritation, and exaggerated muscle stretch reflexes in all four extremities. Cerebrospinal fluid cell count was 832/mm3 and protein was 771 mg/dl. Bacterial culture of the cerebrospinal fluid showed Staphylococcus aureus. A cervical MRI scan with Gd-enhancement revealed focal high intensity signal in the T2-weighted and FLAIR images, at the anterior meninges of the C3-8 segments, the vertebral bodies of C5-6 and the intervertebral disks of C5-6 segment. Her diagnosis was cervical epidural abscess, cervical spondylitis, cervical discitis and meningitis. Antibiotics and steroids improved her symptoms. Six weeks after the onset of symptoms, a cervical MRI scan showed narrowing and synarthrosis in the intervertebral space between C5 and C6. MRI and myelo CT scans demonstrated a newly-formed syrinx from C3-C 7. This was an interesting case of syrinx formation secondary to cervical epidural abscess.

[Acute frontal sinusitis accompanied with extra-dural abscess (a case reported with literature reviewed)]

OBJECTIVE

To investigate the clinical characteristics of acute frontal sinusitis accompanied with extra-dural abscess.

METHOD

A case of acute frontal sinusitis accompanied with extra-dural abscess diagnosed by CT was analyzed, and the relative literatures were reviewed.

RESULT

Headache, high fever and failure to antibiotic therapy were the main three clinical characteristics.

CONCLUSION

It is the most important thing to drainage the abscess except for antibiotic therapy for acute frontal sinusitis accompanied with extra-dural abscess. Antibiotic therapy cannot substitute for surgery.

An eye for trouble: orbital cellulitis

Patients with orbital cellulitis present to emergency departments occasionally. Symptoms usually develop rapidly, with patients being distressed by painful ocular movements and systemic upset. The case of a 24-year-old man who had a 1-month gradual history of intermittent periorbital swelling after a flu-like illness, and subsequently developed a large intracranial extradural abscess eroding through the temporal bone, ultimately requiring neurosurgical intervention is presented. Although orbital and periorbital swelling is common after acute sinusitis, cellulitis and intracranial abscess are rare but potentially life threatening and sight threatening. Accurate diagnosis is therefore of great importance. In this case, the patient presented with few clinical signs but relevant pathology. The importance of assessing ocular movement, which is a major clinical abnormality indicating orbital disorder and thus an aid to accurate diagnosis, should be highlighted.

Pyogenic Cervical Spondylitis with Quadriplegia as a Complication of Severe Burns: Report of a Case

We report a case of cervical pyogenic spondylitis complicated by epidural abscess with quadriplegia during treatment of severe burns. The patient was a 49-year-old man with 3rd-degree burns to 20% of his body, involving the lower extremities. We performed escharectomy of the 3rd-degree necrosis on days 7 and 16, followed by the first skin graft on day 23. Pseudomonas aeruginosa was detected in the postoperative graft wound culture. On day 23 after the skin graft, he became febrile and began to experience cervical pain and muscle weakness of the extremities. By day 24, quadriplegia had developed. A cervical vertebral magnetic resonance imaging (MRI) scan showed pyogenic spondylitis with an epidural abscess, which was causing the quadriplegia. We treated the patient by performing curettage of the pyogenic lesion and anterior fixation of the cervical vertebral bodies. The fact that P. aeruginosa was detected in the pyogenic focus culture indicated that burn wound sepsis was responsible for the infection. This case reinforces that acting on a strong suspicion helps to establish a diagnosis and initiate appropriate treatment early.

Cervical Epidural Abscess in an Afebrile Patient: A Case Report

OBJECTIVE

The aim of the study was to discuss a case of cervical epidural abscess and present the clinical features and diagnosis of this disorder.

CLINICAL FEATURES

A 52-year-old man had severe neck pain for 1 week. He had a long history of chronic recurrent neck pain, including 2 previous neck surgeries. He was afebrile on each visit, but developed rapid onset of motor loss, which necessitated immediate magnetic resonance imaging referral. The patient died in the magnetic resonance imaging tube.

INTERVENTION AND OUTCOME

Because of the aggressive nature of the infection, causing death only 1 week after the initial onset of symptoms, there was no opportunity to institute treatment of the abscess.

CONCLUSION

Spinal epidural abscess is a relatively rare but potentially life-threatening disorder in which the most common initial symptom is spinal pain. Because of this, patients with early spinal epidural abscess will often consult a chiropractic physician or other primary contact spine specialist. It is important for clinicians to be alert to the diagnostic features of spinal epidural abscess so that early treatment can be instituted.

Quadriparesis from a panspinal extradural abscess following pneumococcal meningitis

A 63-year-old male presented with marked quadriparesis, three weeks after a pneumococcal meningitis. The MRI-scan was suggestive for extradural abscess in the craniocervical region extending into the lower thoracic spine. Cervical laminectomy was performed and a large abscess was drained. Culture revealed Streptococcus pneumoniae sensitive to benzylpenicillin. The patient was treated with antibiotics for six weeks. His neurological condition recovered completely, and he walked normally, without support, 6 weeks later. Pneumococcal infection of the extradural space is rare. The course of spinal epidural abscess is unpredictable and may present with quadriplegia. Complete recovery of the neurological deficit may occur if the abscess is drained before any ischaemic insult occurs to the cord.

A quartet of lateral sinus thrombosis, extradural abscess, subdural abscess and occipital abscess: complications of acute mastoiditis in a pre-adolescent child

Neurological complications of acute mastoiditis are rare but can be life threatening. Their presentation may be masked by the use of antibiotics. We present a unique case of acute otitis media progressing to occipital, extradural and subdural abscess formation and lateral sinus thrombosis in a child. The clinical course and management of a pre-adolescent male is presented and discussed. We review the incidence, presentation and treatment of occipital abscesses and lateral sinus thrombosis with acute mastoiditis. Following extended cortical mastoidectomy, neck exploration and broad spectrum intravenous antibiotics, the patient made a full recovery. This is the first reported case of acute mastoiditis associated with occipital abscess in a child. Early, aggressive treatment is required for a successful outcome. The rarity of neurological complications, in addition to the insidious onset and subtle symptoms associated with antibiotic therapy, can make diagnosis extremely difficult. Patients with acute otitis media who fail to respond fully to treatment should be referred early for a specialist otology opinion.