Neurobrucellosis presenting as an intra-medullary spinal cord abscess

Intramedullary Spinal Cord Abscess Management: Case Series, Operative Video, and Systematic Review

BACKGROUND

Intramedullary spinal cord abscess (ISCA) is an extremely rare disease, which has had fewer than 250 reported cases since its initial description in 1830. The condition is limited to level V evidence, limiting the ability for surgeons to characterize and treat it.

OBJECTIVE

To report the cases of 2 patients with ISCA and their surgical management: a 59-year-old woman who presented with progressive right hemiparesis and a 69-old man who presented with acute gait instability and significant bilateral shoulder pain. In addition, to report findings from a systematic literature review and associated logistic regression analysis.

METHODS

A MEDLINE and Embase search was conducted using the keywords "intramedullary," "spinal cord," "abscess," and "tuberculoma" and the results were screened for case reports. A logistic regression model was fit 100 times on data to retrieve predictor odds ratios.

RESULTS

Two hundred case reports of ISCA were identified between 1965 and 2022. Logistic regression determined that the only variables of significance were age (P < 0.01) and antibiotics (P < 0.05).

CONCLUSIONS

Treatment of ISCAs has significantly improved over the years. However, ISCAs are still poorly understood. Our recommendations can be used to guide diagnosis and treatment.

Intramedullary Spinal Cord Abscess with Concomitant Spinal Degenerative Diseases: A Case Report and Systematic Literature Review

Intramedullary spinal cord abscess (ISCA) is a rare clinical pathology of the central nervous system that usually accompanies other underlying comorbidities. Traditionally it has been associated with significant mortality and neurological morbidities because it is often difficult to diagnose promptly, owing to its nonspecific clinical and neuroimaging features. The mortality rate and the outcome of these infections have been improved by the introduction into clinical practice of antibiotics, advanced neuroimaging modalities, and immediate surgery. We report the case of a 65-year-old male patient who presented with a progressive spastic gait and lumbar pain, predominantly in the left leg. An MRI image revealed an expansile intramedullary cystic mass in the thoracic spinal cord, which was initially diagnosed as a spinal tumor. He underwent laminectomy and myelotomy, and eventually the pus was drained from the abscess. The follow-up MRI showed improvement, but the patient’s paraplegia persisted. In light of his persistent hypoesthesia and paraplegic gait with developing neuropathic pain, he was readmitted, and an MRI of his lumbar spine revealed multilevel degenerative disease and tethered spinal cord syndrome with compression of the medulla at the L2–L3 level. The patient underwent central flavectomy with bilateral foraminotomy at the L2–L3 level, and the medulla was decompressed. Postoperatively, his neurological symptoms were significantly improved, and he was discharged from hospital on the third day after admission. In support of our case, we systematically reviewed the recent literature and analyzed cases published between 1949 and May 2022, including clinical features, mechanisms of infection, predisposing factors, radiological investigations, microbial etiologies, therapies and their duration, follow-ups, and outcomes. Initial clinical presentation can be misleading, and the diagnosis can be challenging, because this condition is rare and coexists with other spinal diseases. Hence, a high index of suspicion for making an accurate diagnosis and timely intervention is required to preclude mortality and unfavorable outcomes. Our case is a clear example thereof. Long-term follow-up is also essential to monitor for abscess recurrences.

Skip decompression surgeries in the treatment of holospinal epidural abscess: a case report

INTRODUCTION

Holospinal epidural abscess (HEA) extending from the cervical to the lumbosacral spine is an extremely rare condition. Surgical treatment of HEA, which involves extensive decompression of the spinal lesion is difficult in emergency settings. However, the authors successfully treated a case of HEA in critical condition with severe neurological deficits through a combination of skip decompression surgeries and catheter irrigation.

CASE PRESENTATION

A 73-year-old man complained of neck and back pain and developed muscle weakness in the upper and lower extremities (C5 AIS D tetraplegia). When he was transferred to our hospital, a marked increase in leukocytes (13330/μL) and C-reactive protein levels (32.11 mg/dL) was observed. Magnetic resonance imaging (MRI) revealed a HEA extending from C1 to S2 levels. Therefore, an emergency posterior decompression on C4-5 and T4-7 was performed, followed by catheter irrigation using a venous catheter. Blood and intraoperative isolated microorganisms were identified as Streptococcus intermedius, which is a rare cause of spinal infection. He experienced marked improvement in pain after surgery. Two months after surgery, the epidural abscess completely disappeared. Motor weakness gradually improved, and he was able to walk without support and showed no pain recurrence during the final follow-up (20 months after surgery).

DISCUSSION

Early diagnosis is important for the treatment of HEAs. Therefore, a whole spine MRI is recommended when an extensive spinal epidural abscess is suspected. Decompression surgery at limited spine levels followed by catheter irrigation should be considered in patients with HEA.

Use of an Intracranial Drain as a Conduit for Treatment of an Intracranial Streptococcus intermedius Abscess

Brain abscesses are difficult to manage clinically and often result in a poor outcome. Although surgical and medical therapeutics have progressed, there are still challenges that make treating intracranial abscesses problematic. One of these treatment barriers is the poor penetration of intravenous antibiotics to the infection source through the blood-brain barrier. In this case report, we will discuss the use of a surgical drain as a conduit for direct antibiotic administration for a rare, recurrent Streptococcus intermedius infection. This technique allows us to bypass the blood-brain barrier while also reducing the systemic effects of antibiotics. When used in conjunction with craniotomy and resection, direct antibiotic administration via a surgical drain proved to be effective at treating our patient’s abscess and preventing recurrence.

Evaluation of clinical, diagnostic features and therapeutic outcome of neurobrucellosis: a case series and review of literature

AIM

In this study, we aimed to discuss the clinical features, laboratory findings, treatment and outcome of seven cases of neurobrucellosis from a tertiary care center and review the available global literature.

MATERIALS AND METHODS

The diagnosis of neurobrucellosis was established using the following criteria in our setting: (1) signs and symptoms of neurological infection with examination of cerebrospinal fluid (CSF) revealing signs of meningitis, (2) isolation of Brucella spp. from blood and/or CSF and/or antibody titer ≥1:160 in serum using standard agglutination test (SAT) and/or the presence of anti-Brucella antibodies in CSF and/or detection of Brucella spp.-specific DNA from CSF using PCR. A literature search was performed to review previous cases of neurobrucellosis published worldwide during the last 30 years.

RESULTS

The proportion of neurobrucellosis was 2.8% in our setting. Fever with headache and altered sensorium were the major presenting complaints. Brucella melitensis was isolated from blood culture in 6 patients. From the literature search, a total of 221 cases of neurobrucellosis were reviewed and analyzed. Meningitis (32.6%), loss of hearing (25.8%) and encephalitis (14.9%) were the most common clinical features. Involvement of cranial nerves, polyradiculopathy and paraplegia were the major complications found in patients with neurobrucellosis.

CONCLUSIONS

Neurobrucellosis should always be considered in the differential diagnosis of befitting neurological, rheumatological, and neuropsychiatric presentations in endemic regions for brucellosis. To prevent morbidity and mortality associated with neurobrucellosis, a multimodal diagnostic approach is essential for early and accurate diagnosis and effective treatment.

[Diagnosis and treatment of primary intraspinal abscess]

OBJECTIVE

To summarize the feature and treatment of the primary intraspinal abscess in order to improve the prognosis.

METHODS

In the study, 13 cases of primary intraspinal abscess of the recent 20 years were retrospectively analyzed. The history, etiology, pathogen, surgical methods and prognosis were summarized.

RESULTS

The course of the illness ranged from 7 days to 6 months. All the cases began with pain. Of the 13 patients, 10 had limb weakness. Five had a fever and 8 had increased white blood cells. As for distribution, 1 was in cervical vertebra, 1 in cervicothoracic junction, 1 in thoracic vertebra, 4 in thoracolumbar junction, and 6 in lumbosacral segment. The results of bacterial culture were positive in 4 cases, 3 cases were diagnosed as tuberculosis by pathological examination, and 1 case was recognized as infection of Brucella melitensis bacteria because of prior brucellosis. The pathogen of the remaining cases were unclear. All the cases received surgical treatment and pathology examination. The surgical aim was mainly removal of the lesion, decompression and drainage. Postoperatively anti-infection and glucocorticoid therapy were performed according to the pathogeny results and clinical experience. Incision abscesses were seen in 2 cases and reoperations including debridement and repair with transferred muscle flap were performed. Postoperative follow-up ranged from 6 months to 3 years (mean 1.8 years). One case suffered postoperative recurrence and the abscess spread along the vertebral canal. Reoperation was performed. Infections of all the cases were recovered completely and the nervous system signs were all improved in different degrees.

CONCLUSION

The onset of primary intraspinal abscess is relatively urgent, mainly with pain. The lumbar and sacral vertebra is the predilection site. The bacterial culture is mostly negative. Early operation and use of sufficient amount of broad-spectrum antibiotic are recommended. If the incision abscess forms after the operation, it is advisable to transfer the muscle flap to repair the coloboma on the basis of debridement. In order to relieve edema of spinal cord and nerve root, the glucocorticoid can be used in the escort of antibiotics.

Streptococcus intermedius posterior fossa abscess after a minor dental procedure in an immunocompetent woman

A 52-year-old woman with no relevant previous medical history was diagnosticated of an infratentorial bulky cerebellar mass. The mass showed restricted diffusion on MR images, which was consistent with cerebellar abscess. The patient had undergone a minor dental procedure three weeks before. Microbiological analysis after surgical evacuation of the mass confirmed the presence of Streptococcus intermedius.

Genome Mining and Comparative Analysis of Streptococcus intermedius Causing Brain Abscess in a Child

Streptococcus intermedius (SI) is associated with prolonged hospitalization and low survival rates. The genetic mechanisms involved in brain abscess development and genome evolution in comparison to other members of the Streptococcus anginosus group are understudied. We performed a whole-genome comparative analysis of an SI isolate, LAU_SINT, associated with brain abscess following sinusitis with all SI genomes in addition to S. constellatus and S. anginosus. Selective pressure on virulence factors, phages, pan-genome evolution and single-nucleotide polymorphism analysis were assessed. The structural details of the type seven secretion system (T7SS) was elucidated and compared with different organisms. ily and nanA were both abundant and conserved. Nisin resistance determinants were found in 47% of the isolates. Pan-genome and SNPs-based analysis didn’t reveal significant geo-patterns. Our results showed that two SC isolates were misidentified as SI. We propose the presence of four T7SS modules (I–IV) located on various genomic islands. We detected a variety of factors linked to metal ions binding on the GIs carrying T7SS. This is the first detailed report characterizing the T7SS and its link to nisin resistance and metal ions binding in SI. These and yet uncharacterized T7SS transmembrane proteins merit further studies and could represent potential therapeutic targets.

Intramedullary cervical abscess mimicking a spinal cord tumor in a 10-year-old girl: a case-based review

BACKGROUND

Intramedullary spinal cord abscesses (ISCA) are a rare pathological entity with very few cases reported in the world and may be confused with an intramedullary tumor. Cervical location is the least frequently affected, except for cryptogenic spread, mostly seen in adult patients. Meticulous study of contrast-enhanced MRI pictures has a key role in the diagnosis.

METHOD AND RESULTS

We present a case of a spontaneous cervical ISCA, mimicking a spinal cord tumor, in a pediatric patient with good outcome. A review of the literature shows that this is a life-threatening condition with high chances of rupture and subsequent meningitis.

CONCLUSIONS

We point out that if a solitary cervical spinal cord lesion is surrounded by significant medullar edema associated with fast onset of symptoms, fever, and elevation of WBC, the possibility of a spinal cord abscess should be considered prior to surgery.

Neurological Manifestations of Brucellosis in an Indian Population

Brucellosis is a zoonotic disease causing serious public health problems in countries of the Middle-East and developing countries like India. Neurobrucellosis is one of the devastating complications of this re-emerging zoonosis. The objective of this review was to identify the neurological manifestations of Brucellosis in an Indian population and bring into light the effective modalities used for treating neurobrucellosis. A systematic review of the scientific literature reported in accordance with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines was conducted. Three databases (PubMed, IndMed, and ScienceDirect) were used to analyze retrospectively case reports of sufficient quality for data extraction (from the last 15 years, 2002-2016), and relevant literature was reviewed. Most of the cases had a definite history of exposure to Brucella through occupational contact with cattle, drinking raw milk, or living near unhygienic abattoir or even trips to epidemic areas outside India. The common presentations include fever, meningitis, brisk deep-tendon reflexes, extensor plantars, sensory deficit usually below the twelfth thoracic vertebral level, weakness of lower limbs, ocular signs of papilledema, and retrobulbar neuritis. The usual systemic findings associated were hepatosplenomegaly and weight-loss. Neurobrucellosis needs to be kept in mind in the differential diagnosis of fever of unknown origin involving neurological symptoms and systemic involvement. Prognosis is good if there is a combination of antibiotics, each with different mechanisms of action given in full dose. Suitable measures for its prevention are also suggested.

Epidemiological and clinical characteristics of neurobrucellosis case patients in Tunisia

OBJECTIVE

We aimed to identify epidemiological, clinical, therapeutic, diagnostic, and outcome characteristics of neurobrucellosis case patients in Tunisia.

PATIENTS AND METHODS

We conducted a retrospective and descriptive study over a 17-year period (January 1997-December 2013). We included all neurobrucellosis patients hospitalized in the infectious disease department of La Rabta Hospital of Tunis during the study period.

RESULTS

A total of 13 patients were included in the study: 9 men and 4 women. Mean age was 31.6 years. Six patients presented with meningitis, three with encephalitis, two with meningoencephalitis, and two with meningo-myeloradiculitis. All patients had a lumbar puncture performed. Eleven patients had an abnormal cerebrospinal fluid (CSF) (84.6%): lymphocytic pleocytosis in seven patients, high level of CSF proteins in 11, and low level of CSF glucose in seven. All patients had a positive Brucella serological test in blood. A Brucella serological test was also performed in CSF and was positive for 10 patients (77%). A total of nine patients had a cerebral CT scan and/or MRI performed and abnormalities were observed in six patients. Antibiotic therapy was prescribed to all patients: a combination of rifampicin and co-trimoxazole (n=9) or doxycycline (n=4) for an average duration of eight months. Two patients also received steroids. A positive outcome was observed in 10 patients. Three patients were lost to follow up.

CONCLUSION

Brucellosis may be severe when neurological involvement occurs. Brucellosis should be considered in the event of any neurological involvement associated with suggestive epidemiological features.

Spinal brucellosis

Spinal involvement in human brucellosis is a common condition and a significant cause of morbidity and mortality, particularly in endemic areas, because it is often associated with therapeutic failure. Most chronic brucellosis cases are the result of inadequate treatment of the initial episode. Recognition of spinal brucellosis is challenging. Early diagnosis is important to ensure proper treatment and decrease morbidity and mortality. Radiologic evaluation has gained importance in diagnosis and treatment planning, including interventional procedures and monitoring of all spinal infections.

Brain abscess associated with patent foramen ovale

BACKGROUND

Brain abscesses can develop with Tetralogy of Fallot and pulmonary anterior venous fistula with large right-to-left shunt. However, some patients exhibit cryptogenic brain abscess (CBA) in the absence of any such congenital disease or other infections. Patent foramen ovale (PFO) is a very common disease that exhibits right-to-left shunt. This study reports the potential for concern between CBA and PFO.

METHODS

We enrolled patients with CBA in our hospital between January 2003 and January 2013. Patients underwent transesophageal echocardiography (TEE) with contrast medium to investigate the presence of PFO.

RESULTS

Seven patients were included. Four were females, and the mean age was 67.7 ± 9.2 years. In all patients, TEE failed to reveal any new findings, however, six patients had PFO, and another patient had pulmonary arteriovenous shunt. Four patients had odontopathy.

CONCLUSION

In this study, all CBA patients exhibited right-to-left shunt. CBA might be caused by paradoxical embolization of a bacterial mass via PFO. Thus, more patients with CBA need to undergo TEE to detect PFO.

From a simple chronic headache to neurobrucellosis: a case report

Brucellosis is an infectious disease with high incidence in Iran. Neurobrucellosis is a focal complication of brucellosis affecting both central and peripheral nervous system presenting with a varieties of signs and symptoms. The most reported manifestations are meningitis and meningoencephalitis. In this report, we will describe a case of a young woman affected by neurobrucellosis presenting with chronic progressive headache and papilledema.

The role of Streptococcus intermedius in brain abscess

Brain abscess represents a significant medical problem, despite recent advances made in detection and therapy. Streptococcus intermedius, a commensal organism, has the potential to cause significant morbidity. S. intermedius expresses one or more members of a family of structurally and antigenically related surface proteins termed antigen I/II, which plays a potential role in its pathogenesis. It is involved in binding to human fibronectin and laminin and in inducing IL-8 release from monocytes, which promotes neutrophil chemotaxis and activation. There are few published data on the role of this organism in brain abscess. This review focuses on the clinical evidence, pathogenic role, mechanism of predisposition, and currently employed strategies to fight against S. intermedius associated to brain abscess.

Acute onset intramedullary spinal cord abscess with spinal artery occlusion: a case report and review

Intramedullary spinal cord abscess (ISCA) without meningitis is an extremely rare entity in the central nervous system, and it is often difficult to diagnose immediately, and no definitive imaging findings have been established. We experienced the case of a 61-year-old male who presented with a sudden onset back pain without fever following rapidly worsening paraparesis for 3 days, who subsequently become unable to walk. According to the initial MRI and 3D-CTA, the presumptive diagnosis was spinal infarction due to spinal artery embolism. However, his symptoms did not improve, despite the gradual changes in MRI following antiplatelet therapy. He underwent a biopsy in an attempt to prevent the lesion from progressing toward the upper spinal cord. The pathological examination revealed an intramedullary abscess, so we performed a midline myelotomy and drained the pus from the abscess. After surgery, MRI showed improvement, but the patient's paraplegia persisted. To the best of our knowledge, this is the first case report of spinal cord abscess with the confirmation of spinal artery occlusion on angiography, which could have been caused by a bacterial embolism. We herein discuss its possible etiology and also review recent reports on ISCA.

Management of intramedullary spinal cord abscess: experience with four cases, pathophysiology and outcomes

Intramedullary spinal cord abscess (ISCA) in children is extremely a rare infection of the central nervous system (CNS); and probably a devastating neurological condition. Clinical awareness of patients at risk is crucial for early diagnosis and intervention; as this entity is one of the treatable conditions of paraparesis. Association with congenital neuro-ectodermal abnormality in children is frequent. This pathology highlights the importance of complete neurological checks of infants as a part of their routine physical examination and early management of patients with congenital dermal sinus, prophylactic surgical resection of such a congenital anomaly is recommended by most authors to prevent serious infections of the CNS. However, once the abscess is established; immediate surgical drainage along side adequate antibiotics should be instituted. This may guarantee improving neurological outcome. In this communication, the authors present their experience with four cases of ISCA in children treated successfully with surgical drainage, intravenous antibiotics and neuro rehabilitation between 2001 and 2006 and discuss their results. We concluded that early diagnosis and treatment is essential; before a devastating mechanico-vascular insult of the spinal cord is established from rapid formation of the abscess and a swift expansion of the spinal cord within the limited intraspinal space.

Intramedullary lesions of the conus medullaris: differential diagnosis and surgical management

The medullary conus represents a distinct entity of the spinal cord regarding its anatomical, clinical and microsurgical features. An overview of the pathologic processes of this region is provided. Epidemiological, clinical and neuroradiological characteristics of neoplastic (glial tumors, non-glial tumors, metastasis, primary melanomas) and non-neoplastic lesions (granulomatous lesions, abscess, parasitic infections, vascular, demyelinating and dysembryogenetic lesions) are discussed. Main MR imaging characteristics used to differentiate neoplastic from non-neoplastic lesions consist in pathological spinal cord expansion, gadolinium-enhancement and tumoural cyst formation. Management strategies differ substantially, depending on the kind of lesion. According to the suspected pathological entity radical resection, biopsy or conservative treatments are reasonable options. Intraoperative electrophysiological monitoring is a fundamental part of the surgical setting.

Therapeutic options for human brucellosis

Worldwide, human brucellosis is the most common zoonotic disease and it has gained increasing interest because of the potential use of Brucella as a biological weapon. Monotherapy for brucellosis is associated with a high relapse rate and dual therapy in different combinations is more efficacious. The combination regimen of intramuscular streptomycin with an oral tetracycline resulted in fewer relapses than the doxycycline-rifampin combination in meta-analysis and prospective studies, although the use of doxycycline and rifampin is a reasonable choice in certain conditions. Longer duration and triple antimicrobial therapy appear to improve outcome and prevent relapses, especially in patients with focal disease. Recently, the use of gentamicin-loaded microparticles and the use of new antibiotics, such as tigecycline, may hold future promise. In addition, there are a few studies of the enhanced effect of immune response stimulators, such as levimasole and IFN-2, in the treatment of brucellosis. The development of an effective subcellular Brucella vaccine would be an important step forward to curtail the disease. However, currently and for the near future, only the control of animal disease is possible using vaccine strategies.

Management of neurobrucellosis: an assessment of 11 cases

OBJECTIVE

The central nervous system involvement of Brucellosis causes a hard to treat infection with multiple sequelae. The aim of this paper is to discuss the course of neurobrucellosis in response to therapy.

PATIENTS AND METHODS

Patients with neurobrucellosis were evaluated. The diagnosis was established by the isolation of bacteria, abnormal CSF findings and positive serology. Ceftriaxone, rifampicin, doxycycline and trimethoprim sulfamethoxazole were the antibiotic choices for these cases.

RESULTS

We present 11 cases with neurobrucellosis. None of our patients died, albeit one case has a critical situation due to subarachnoid hemorrhage and its' concordant sequelae. Only one of four patients with walking difficulty and two with hearing loss were normalized with therapy. Imaging techniques did not provide any specific contribution regarding the Brucella infection.

CONCLUSIONS

Parenteral ceftriaxone should be used as an initial alternative in the management of neurobrucellosis. Although the therapy should be individualized, the duration of therapy should be a minimum of six months with suitable antibiotics.

Cervical intramedullary granuloma of Brucella: a case report and review of the literature

The aim of this study was to present a unique case of intramedullary brucellar granuloma (IBG) and to discuss the diagnosis and management. To our knowledge, only one case of thoracic IBG has been reported previously, and our case is the first in cervical spine. A 35-year-old female patient was admitted with headache, pain and weakness in her four extremities. She had no gastrointestinal symptoms and fever. She had been diagnosed with Brucella meningitis 3 months ago and a triple therapy of doxycyclin, rifampicin and trimetoprim/sulfametoxazol (TMP/SMZ) had been started. Medical history revealed that she had ingested raw cheese and taken her medication improperly. Loss of strength was detected in her four extremities, which led us to assume the formation of a mass lesion at cervical level. Therefore, we performed a magnetic resonance imaging scan and found enhancement of an intramedullary mass lesion at cervical 1-2 level. Diagnosis of neurobrucellosis was confirmed by titer of >1/160 Brucella antibodies both in blood and cerebrospinal fluid. Based on these findings, brucellar granuloma of cervical spine was diagnosed and a combination therapy of doxycyclin, TMP/SMZ and rifampicin was administered for additional 6 months. At the ninth month of treatment, the patient recovered both radiologically and clinically. Our case is unique, in terms of cervical IBG formation. The excellent response to antimicrobial therapy in our patient suggests that, a trial of medical treatment for 6 months may be effective in such cases.