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Nakamura Y, Namba T, Sakurai M, Yasui M. Silent spinal epidural abscess due to facet joint arthritis. IDCases 2023; 33:e01887. [PMID: 37680212 PMCID: PMC10480523 DOI: 10.1016/j.idcr.2023.e01887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/24/2023] [Accepted: 08/27/2023] [Indexed: 09/09/2023] Open
Abstract
Spinal epidural abscess (SEA) is an abscess that forms between the dura mater and vertebrae. SEA is characterized by back pain and neuropathy associated with fever, of which early diagnosis and treatment are necessary to avoid irreversible neurological sequelae. However, its diagnosis is often difficult because specific symptoms are rarely present in the early stages of the disease. A 25-month-old boy, healthy by nature and free of risk factors, was referred and admitted for fever symptoms only, without back pain or neurological symptoms. We focused on the residual activation of the coagulation-fibrinolytic system, which was contrary to the response to therapy, and were able to establish a diagnosis of SEA. After the initiation of antibiotics, the patient responded well to treatment and made a mild recovery without the need for surgical intervention. To date, there are no reported cases of SEA with only febrile symptoms without localized spinal cord tenderness. SEA is easily overlooked and should be considered in the differential diagnosis of pediatric fever of unknown origin. Although imaging studies have drawbacks, such as radiation exposure and sedation, they should be immediately performed if SEA is suspected.
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Affiliation(s)
- Yuta Nakamura
- Department of Pediatrics, Fukuyama City Hospital, Fukuyama, Japan
| | - Takahiro Namba
- Correspondence to: Department of Pediatrics, Fukuyama City Hospital, 5-23-1, Zaocho, Fukuyama, Hiroshima 721-8511, Japan.
| | - Momoko Sakurai
- Department of Pediatrics, Fukuyama City Hospital, Fukuyama, Japan
| | - Masato Yasui
- Department of Pediatrics, Fukuyama City Hospital, Fukuyama, Japan
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Vig KS, Amarante M, Hutchinson I, Lawrence JP. Pediatric Group A streptococcal spinal epidural abscess presenting with recurrent symptoms of viral illness: An operative case report. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 6:100067. [PMID: 35141632 PMCID: PMC8820052 DOI: 10.1016/j.xnsj.2021.100067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 11/06/2022]
Abstract
Background Spinal epidural abscess (SEA) in children is a rare condition with dangerous sequelae, and with only 22 other cases reported in the literature, treatment algorithms are poorly understood. Quick identification of the classic tried of sepsis, back pain and neurological deficit is critical. Source identification difficult and often cannot be identified. Reported pathogens include varicella-zoster virus, S. aureus, and S pyogenes. Case description We report a case of spontaneous pediatric SEA in a 22-month old female without obvious neurologic deficit, who underwent a T10-11 decompressive laminotomy and evacuation of abscess and subsequent 3-week course of intravenous ceftriaxone for culture positive S. pyogenes Outcome The patient showed marked improvement in symptoms after decompression. 5 weeks postoperatively after transitioning from intravenous ceftriaxone to oral ceftin, the patient redeveloped a deep space infection and was taken back for a repeat debridement. The cultures from this procedure were negative and the patient was discharged on oral clindamycin. Conclusions Pediatric spontaneous SEA is a rare condition and early diagnosis and surgical intervention if indicated can prevent dangerous sequelae. Further studies into the surgical indications for decompression will aid in algorithmic decision making.
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Septic Arthritis of Facet Joint in Children: A Systematic Review and a 10-year Consecutive Case Series. Pediatr Infect Dis J 2021; 40:411-417. [PMID: 33538543 DOI: 10.1097/inf.0000000000003031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Due to the low resolution of historical imaging technologies, descriptions of Septic Arthritis of Facet Joint (SAFJ) in children are scarce, though severe cases are known. We first aimed to estimate the incidence rate of SAFJ in children; we further aimed to specify SAFJ clinical, imaging and laboratory findings, and identify avenues for appropriate management. METHODS A 10-year consecutive SAFJ case series using our imaging center database combined with a 50-year systematic review of literature cases. RESULTS The mean ± SD incidence of pediatric SAFJ was 0.23 ± 0.4/100,000 children-years. The key symptoms were potty refusal (in toddlers) or painful sitting (78%) and lateralized signs (paravertebral tenderness and/or swelling, 88%). SAFJ diagnosis and extension were obtained using magnetic resonance imaging (MRI) (94%), and found an epidural extension in 8/16 cases. The mean duration of antibiotic treatment was 5.1 weeks. The compliance with guidelines was 79% for empiric and 62% for targeted antibiotic therapies. CONCLUSIONS SAFJ incidence in children is much greater than expected from the literature. Half of cases were complicated by an epidural infection. Simple clinical symptoms detected as early as the bedside allow a strong suspicion of SAFJ, justifying the use of a first-line MRI to confirm the diagnosis and precisely describe the extension. Focusing on simple clinical signs is key to justify the transfer of a child or the shortening of the delay to obtain an MRI. However, as MRI availability increases in most Western countries, and the capacity for diagnosis increases, the awareness of SAFJ must be spread to avoid missed cases.
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Houston R, Gagliardo C, Vassallo S, Wynne PJ, Mazzola CA. Spinal Epidural Abscess in Children: Case Report and Review of the Literature. World Neurosurg 2019; 126:453-460. [PMID: 30797918 DOI: 10.1016/j.wneu.2019.01.294] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 01/29/2019] [Accepted: 01/31/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Spinal epidural abscess (SEA) is a rare but serious infection in the epidural space along the spinal cord. SEA should be considered in patients with backache, fever, neurological deficits and/or spinal tenderness. Early diagnosis is imperative to prevent permanent neurological sequelae. CASE DESCRIPTION We report a case of lumbar SEA in a 13-year-old girl who was immunocompetent and presented with spinal tenderness, back pain and 4 days of fever. A lumbar magnetic resonance imaging demonstrated an epidural abscess from L3-S1. She had emergent surgical intervention. Cultures grew methicillin-susceptible Staphylococcus aureus. She was also given long-term systemic antibiotics and she made a complete recovery within 2 months. CONCLUSIONS SEA in an immunocompetent pediatric without risk factors is an extremely rare condition. In the English-language literature, there are only 30 reported cases in the past 19 years; our case brings the total to 31. Non-surgical treatment has been successful in both adult and pediatric patients under certain conditions. Still, there exists a risk of deterioration with non-surgical management, even in patients for whom treatment is begun in the absence of neurologic deficits. Tracking neurological deficits in children can be challenging, particularly in young children who are non-verbal and not yet ambulating, and a reliable neurologic examination is a critical component of non-surgical care. In consideration of these facts and the accelerated time frame of deterioration, once neurologic deficits are present, surgery plus systemic antibiotics remains the standard of care for pediatric SEA patients, with each individual case meriting review of the full clinical picture.
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Affiliation(s)
- Rebecca Houston
- Rowan University School of Medicine (UMDNJ), Stratford, New Jersey, USA.
| | - Christina Gagliardo
- Division of Pediatric Infectious Diseases, Goryeb Children's Hospital, Atlantic Health System, Morristown, New Jersey, USA; Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sheryl Vassallo
- Division of Pediatric Infectious Diseases, Goryeb Children's Hospital, Atlantic Health System, Morristown, New Jersey, USA
| | - Peter J Wynne
- Department of Radiology, Morristown Medical Center, Morristown, New Jersey, USA
| | - Catherine A Mazzola
- Division of Pediatric Infectious Diseases, Goryeb Children's Hospital, Atlantic Health System, Morristown, New Jersey, USA
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Fotaki A, Anatoliotaki M, Tritou I, Tzagaraki A, Kampitaki M, Vlachaki G. Review and case report demonstrate that spontaneous spinal epidural abscesses are rare but dangerous in childhood. Acta Paediatr 2019; 108:28-36. [PMID: 30222897 DOI: 10.1111/apa.14579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 07/03/2018] [Accepted: 09/12/2018] [Indexed: 01/27/2023]
Abstract
AIM A spinal epidural abscess (SEA) is a rare paediatric bacterial infection, with possible devastating neurological sequelae. We explored localisation in the cervical segment, which is unusual, but more dangerous, than other SEAs. METHODS We describe 22 cases (12 male) of paediatric SEAs without risk factors: 21 from a literature search from 2000 to 2017 and a 30-month-old boy with a spontaneous cervical SEA due to Group A Streptococcus. RESULTS The average age was eight years and the symptoms were mainly fever, back pain and motor deficit, with an aetiological diagnosis in 68%. Methicillin-sensitive Staphylococcus aureus was isolated in six patients, methicillin-resistant Staphylococcus aureus in two, Staphylococcus aureus with unknown susceptibility patterns in three and Group A Streptococcus in four. All patients underwent gadolinium-enhanced magnetic resonance imaging and most abscesses were localised in the thoracic and lumbar areas. More than half (59%) underwent surgery to remove pus and granulation tissue and nine were just treated with antimicrobial therapy for an average of 5.3 weeks. Most patients had good outcomes. CONCLUSION SEAs were underestimated in children due to the rarity and spectrum of differential diagnoses. Timely diagnosis, immediate antibiotics, spinal magnetic resonance imaging and prompt neurosurgical consultations were essential for favourable outcomes.
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Affiliation(s)
| | | | - Ioanna Tritou
- Radiology Department Venizeleio General Hospital Crete Greece
| | | | - Maria Kampitaki
- Pediatric Department University Hospital of Crete Crete Greece
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Dhanju S, Al-Saleh S, Amin R, Weiss SK, Zweerink A, Toulany A, Murray BJ, Narang I. A retrospective analysis of clinical characteristics of childhood narcolepsy. Paediatr Child Health 2018; 23:e95-e101. [PMID: 30455579 PMCID: PMC6234419 DOI: 10.1093/pch/pxx205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
AIM Narcolepsy, encompassing excessive daytime sleepiness (EDS), cataplexy, sleep paralysis and hypnogogic hallucinations, was previously considered rare in childhood. Recently, cases of childhood narcolepsy have increased significantly and the reasons for this may include the increasing awareness of narcolepsy as well as the H1N1 vaccination. The aim of this study was to describe the clinical characteristics of childhood narcolepsy, specifically focusing on cataplexy subtypes that may facilitate early recognition of narcolepsy. METHODS We retrospectively reviewed and analyzed the medical records of 33 children diagnosed with narcolepsy at the Hospital for Sick Children, in Toronto, Ontario. All patients were seen prior to 18 years of age and symptoms were self-reported by parents and/or children themselves. RESULTS At presentation, 32 of 33 children reported EDS and 28 of 33 reported cataplexy. Among the 28 patients with cataplexy, 18 of 28 reported cataplexy referred to as 'cataplectic facies' (e.g., facial hypotonia and/or tongue protrusion) while 10 of 28 patients reported characteristic cataplexy, defined as bilateral loss of muscle tone. Children with cataplectic facies reported higher BMI z-scores compared to those with characteristic cataplexy, 1.8 and 0.8, respectively. Children with cataplectic facies also tended to be younger than those with characteristic cataplexy, 9.2 and 11.8 years of age, respectively. Cataplectic facies appear to be related to narcolepsy close to disease onset. CONCLUSIONS Children, especially young, obese children, presenting with a history of EDS with associated facial hypotonia or tongue protrusion raises the index of suspicion of narcolepsy and should prompt a referral to a specialized sleep facility to establish the diagnosis.
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Affiliation(s)
- Simranpal Dhanju
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario
| | - Suhail Al-Saleh
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario
- University of Toronto, Toronto, Ontario
| | - Reshma Amin
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario
- University of Toronto, Toronto, Ontario
| | - Shelly K Weiss
- University of Toronto, Toronto, Ontario
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario
| | - Allison Zweerink
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario
| | - Alene Toulany
- University of Toronto, Toronto, Ontario
- Division of Adolescent Medicine, Hospital for Sick Children, Toronto, Ontario
| | - Brian J Murray
- University of Toronto, Toronto, Ontario
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Indra Narang
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario
- University of Toronto, Toronto, Ontario
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Fakhouri F, Ghazal A, Alnaeb H, Hezan R, Araj J. Spinal-epidural Abscess Presenting as an Acute Abdomen in a Child: A Case Report and Review of the Literature. Asian J Neurosurg 2018; 13:1247-1249. [PMID: 30459907 PMCID: PMC6208252 DOI: 10.4103/ajns.ajns_177_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Abdominal presentations in patients with spinal–epidural abscess (SEA) are not uncommon. However, it needs to be continually emphasized that the atypical presentations of these diseases could delay the timely diagnosis and consequently prompt management, which threatens spinal cord, leading to potential to paralysis or even death. We report a case of a young girl who presented with abdominal pain and fever. The diagnosis of SEA was unfortunately so delayed that the patient did not show any functional recovery postoperatively. This report aims to highlight the importance of high level of clinical suspicion to recognize an atypical presentation of the SEA. Moreover, the fully detailed history-taking and physical examination are of paramount importance. Spinal underlying pathologies should always be considered as a cause of abdominal pain, especially in children.
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Affiliation(s)
- Fakhr Fakhouri
- Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Aleppo University Hospital, University of Aleppo, Aleppo, Syria
| | - Ahmad Ghazal
- Department of Surgery, Aleppo University Hospital, University of Aleppo, Aleppo, Syria
| | - Hasnaa Alnaeb
- Faculty of Medicine, Aleppo University Hospital, University of Aleppo, Aleppo, Syria
| | - Rasha Hezan
- Faculty of Medicine, Aleppo University Hospital, University of Aleppo, Aleppo, Syria
| | - Joudi Araj
- Faculty of Medicine, Aleppo University Hospital, University of Aleppo, Aleppo, Syria
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Paraspinal and Extensive Epidural Abscess: The Great Masqueraders of Abdominal Pain. Case Rep Neurol Med 2016; 2015:103624. [PMID: 26770847 PMCID: PMC4684844 DOI: 10.1155/2015/103624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Accepted: 11/22/2015] [Indexed: 11/17/2022] Open
Abstract
Paraspinal and epidural abscesses are rare conditions often diagnosed later in the disease process that can have significant morbidity and mortality. Predisposing risk factors include diabetes, human immunodeficiency virus, intravenous drug abuse, and previous history of spinal surgery or injection. They can threaten the spinal cord by compressive effect, leading to sensory motor deficits and ultimately paralysis and death. Diagnosis may be a challenge due to the delayed presentation of nonspecific back pain or radicular pain such as chest pain or abdominal pain. We present a rare case on a patient with periumbilical pain, constipation, and urinary retention who was ultimately diagnosed with a paraspinal abscess extending into the epidural space from T1 to S2. He underwent decompressive laminectomy with incision and drainage of the abscesses. The patient made an excellent recovery postoperatively, and repeat magnetic resonance imaging at six weeks showed resolution of the abscess.
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Vergori A, Cerase A, Migliorini L, Pluchino MG, Oliveri G, Arrigucci U, De Luca A, Montagnani F. Pediatric spinal epidural abscess in an immunocompetent host without risk factors: Case report and review of the literature. IDCases 2015; 2:109-15. [PMID: 26793474 PMCID: PMC4712210 DOI: 10.1016/j.idcr.2015.09.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/29/2015] [Accepted: 09/30/2015] [Indexed: 11/28/2022] Open
Abstract
Spinal epidural abscesses (SEAs) are unusual bacterial infections, with possible devastating neurologic sequelae. Despite abundance of case series in adults, reports in children are scanty. We describe a spontaneous SEA due to methicillin susceptible Staphylococcus aureus (MSSA) in a previously healthy 15-year old male, and we perform a literature review regarding management of pediatric SEAs without risk factors, from 2001 to 2014. We found a total of 12 cases (8 males, average age 9.6 years). Clinical presentation was mainly fever, back pain and elevation of inflammation markers. All cases were initially misdiagnosed. Lumbar puncture was performed in 36% of patients. Etiological diagnosis was obtained in 8 cases. MSSA was isolated in 4 patients, methicillin-resistant S. aureus in 1 patient, and S. aureus with unknown susceptibility patterns in 2 cases. The average of therapy duration was 6 weeks. Patients’ spine was always evaluated by gadolinium-enhanced magnetic resonance imaging; most abscesses were localized at thoracic and lumbar area, without osteomyelitis. In 8 cases, laminectomy and/or abscess drainage were performed in association with medical therapy; 3 cases were successfully treated with antimicrobial therapy only; no data were available in one case. A good outcome was obtained in all patients, except a reported residual headache and paraspinal pain lasting for 3 years. The rarity and the possible differential diagnosis can lead to underestimate SEA occurrence in children without risk factors. It seems therefore essential to maintain a high attention to pediatric SEAs. A prompt diagnosis and adequate therapy are essential prognostic factors for remission.
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Affiliation(s)
- Alessandra Vergori
- University Division of Infectious Diseases, Hospital Department of Specialized and Internal Medicine, Siena, Italy
| | - Alfonso Cerase
- Unit of Neuroimaging and Neurointervention, Hospital Department of Neurological and Sensorial Sciences, University Hospital of Siena, Siena, Italy
| | - Lucia Migliorini
- University Division of Infectious Diseases, Hospital Department of Specialized and Internal Medicine, Siena, Italy
| | - Maria Grazia Pluchino
- Unit of Neurosurgery, Hospital Department of Neurological and Sensorial Sciences, University Hospital of Siena, Siena, Italy
| | - Giuseppe Oliveri
- Unit of Neurosurgery, Hospital Department of Neurological and Sensorial Sciences, University Hospital of Siena, Siena, Italy
| | - Umberto Arrigucci
- Unit of Neuroimaging and Neurointervention, Hospital Department of Neurological and Sensorial Sciences, University Hospital of Siena, Siena, Italy
| | - Andrea De Luca
- University Division of Infectious Diseases, Hospital Department of Specialized and Internal Medicine, Siena, Italy; Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Francesca Montagnani
- University Division of Infectious Diseases, Hospital Department of Specialized and Internal Medicine, Siena, Italy; Department of Medical Biotechnologies, University of Siena, Siena, Italy
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