[An enormous epidural abscess secondary to cranial metastasis of a lung tumor]

Epiduralis abscessus a leggyakrabban otitis media, sinusitis és mastoiditis következtében alakul ki. Ezekben az esetekben a kórokozók a legtöbbször a vénás és artériás rendszeren keresztül jutnak az epiduralis térbe, míg nyílt törések vagy idegsebészeti műtétek során direkt módon is kerülhetnek baktériumok a koponyacsont és a dura közé. Esetismertetésünk irodalmi ritkaságnak tekinthető, mivel az enormis nagyságú epiduralis tályog kialakulásában szerepet játszott a tüdődaganat áttéte miatt kialakult craniumdestrukció, mely megnyitotta a nem steril sinusokat és a mastoid rendszert az epiduralis tér irányába. A gyors állapotromlásban szerepet játszott a beteg szegényes együttműködése és krónikus alkoholizálása. Orv Hetil. 2024; 165(2): 69–73.

Comparison of endoscopic sinus sampling versus intracranial sampling for microbiological diagnosis of intracranial infection in children: a case series and literature review

INTRODUCTION

Intracranial infection is often associated with contiguous sinus infection, with Streptococcus intermedius being the most common pathogen. Microbiological assessment is possible via sinus or intracranial sampling. While a sinus approach is minimally invasive, it is not clear whether this yields definitive microbiological diagnosis leading to optimized antimicrobial therapy and avoidance of intracranial surgery.

METHODS

A retrospective review of a prospectively collected electronic departmental database identified patients between 2019 and 2022. Further demographic and microbiological information was obtained from electronic patient records and laboratory management systems.

RESULTS

Thirty-one patients were identified with intracranial subdural and/or epidural empyema and concurrent sinus involvement during the 3-year study period. The median age of onset was 10 years with a slight male predominance (55%). All patients had intracranial sampling with 15 patients undergoing sinus sampling in addition. Only 1 patient (7%) demonstrated identical organism(s) grown from both samples. Streptococcus intermedius was the most common pathogen in intracranial samples. Thirteen patients (42%) had mixed organisms from their intracranial cultures and 57% of samples undergoing bacterial PCR identified additional organisms, predominantly anaerobes. Sinus samples had a significant addition of nasal flora and Staphylococcus aureus which was rarely grown from intracranial samples. Of concern, 7/14 (50%) of sinus samples did not identify the main intracranial pathogen diagnosed on intracranial culture and additional PCR. Literature review identified 21 studies where sinus drainage was used to treat intracranial empyemas, with only 6 authors reporting concurrent microbiology results. This confirmed our cohort to be the largest comparative study in the current literature. No center has observed a greater than 50% concordance in microbiological diagnoses.

CONCLUSION

Endoscopic sinus surgery may have therapeutic benefit, but it is not an appropriate approach for microbiological diagnosis in pediatric subdural empyemas. High rates of contaminating nasal flora can lead to misdiagnosis and inappropriate treatment. Routine addition of 16S rRNA PCR to intracranial samples is recommended.

[Febrile cervicalgia revealing infectious epiduritis : a case report]

Infectious epiduritis and epidural abscesses are relatively rare pathologies but with important neurological consequences. A low incidence associated with an insidious clinical presentation leads to frequent delays in diagnosis, which worsen the prognosis of patients with the development of neurological deficits. While the evaluation of risk factors, a careful clinical examination and biological tests can guide to the diagnosis, the key examination remains magnetic resonance imaging (MRI) while lumbar puncture remains contraindicated. Although surgery (spinal decompression) has long been the treatment of choice, the current management of patients with infectious epiduritis is debated between surgery and conservative treatment with systemic antibiotic therapy.

Spinal Epidural Abscess and Strep Pharyngitis

Spinal epidural abscesses (SEA) require prompt diagnosis to avoid devastating consequences. Here, we discuss the case of a healthy 20-year-old college student-with a recent diagnosis of strep pharyngitis-who presented with neck pain, fever, and a neurologic deficit-the most common symptoms of SEA. Magnetic resonance imaging revealed a T1-postcontrast, peripherally enhancing epidural collection from C3-T5 with associated cord compression and T3 osteomyelitis. The patient was treated with emergent skip hemilaminectomies for abscess evacuation. Surgical cultures grew Fusobacterium necrophorum, a highly unusual pathogen in SEA. It is an oral anaerobe that translocated through the mucosa in the setting of strep pharyngitis. We treated the patient with ceftriaxone for 6 weeks. The patient had a full neurologic recovery and remains without recurrence of infection 11 months postoperatively. Healthy patients without obvious risk factors may present with SEA, highlighting the need for atypical cases such as these to be brought to clinicians' attention.

Review of management practices of sinogenic intracranial abscesses in children

OBJECTIVE

This study aimed to evaluate the management practices and outcomes in children with sinogenic intracranial suppuration.

METHOD

This was a retrospective cohort study in a single paediatric tertiary unit that included patients younger than 18 years with radiologically confirmed intracranial abscess, including subdural empyema and epidural or intraparenchymal abscess secondary to sinusitis. Main outcomes studied were rate of return to the operating theatre, length of hospital stay, death in less than 90 days and neurological disability at 6 months.

RESULTS

A cohort of 39 consecutive patients presenting between 2000 and 2020 were eligible for inclusion. Subdural empyema was the most common intracranial complication followed by extradural abscess and intraparenchymal abscess. Mean length of hospital stay was 42 days. Sixteen patients were managed with combined ENT and neurosurgical interventions, 15 patients underwent ENT procedures alone and 4 patients had only neurosurgical drainage. Four patients initially underwent non-operative management. The rates of return to the operating theatre, neurological deficits and 90-day mortality were 19, 9 and 3, respectively, and were comparable across the 4 treatment arms. In the univariate logistic regression, only the size of an intracranial abscess was found be associated with an increased likelihood of return to the operating theatre, whereas combined ENT and neurosurgical intervention did not result in improved outcomes.

CONCLUSION

Sinogenic intracranial abscesses are associated with significant morbidity and mortality. The size of an intracranial abscess has a strong association with a need for a revision surgery.

Bilateral pterygoid abscesses in a patient with Lemierre's syndrome

Patients with Lemierre's syndrome may have complications such as lung lesions, large joint arthritis and central nervous system involvement. However, complications involving a pterygoid abscess have scarcely been reported. Here, we report a case of bilateral Lemierre's syndrome accompanied with an intracranial epidural abscess and bilateral pterygoid abscesses. A woman in her 70s presented to the emergency room with a decreased level of consciousness. Infection was suspected, and Slackia exigua and species of Fusobacterium were identified in blood cultures, which suggested that the origin of infection was odontogenic, particularly as the patient had poor oral hygiene. Head and neck CT with contrast enhancement revealed bilateral internal jugular vein thrombophlebitis, septic pulmonary embolism, frontal epidural abscess and bilateral pterygoid abscesses. After antibiotic treatment and drainage, her condition improved. Pterygoid abscesses should be recognised as a rare complication of Lemierre's syndrome, especially when the infection origin is odontogenic.

Mortality, complication risks, and clinical outcomes after surgical treatment of spinal epidural abscess: a comparative analysis of patients aged 18-64 years, 65-79 years, and ≥ 80 years, with a 3-year follow-up

Spinal epidural abscess (SEA) with pyogenic vertebral osteomyelitis (PVO) is a rare illness with a steadily increasing incidence. However, comparative analyses of young and older patients with SEA are lacking. We aimed to compare the clinical course of patients aged 18-64 years, 65-79 years, and ≥ 80 years undergoing surgery for SEA. Clinical and imaging data were retrospectively collected from the institutional database between September 2005 and December 2021. Ninety-nine patients aged 18-64 years, 45 patients aged 65-79 years, and 32 patients ≥ 80 years were enrolled. Patients ≥ 80 years presented with a poorer baseline history (9.2 ± 2.4), as indicated by the CCI, than their younger counterparts (18-74 years: 4.8 ± 1.6;6.5 ± 2.5; p < 0.001). Patients aged 65-79 years and 80 years had a significantly longer length of stay. In-hospital mortality was significantly higher in those aged ≥ 80 years compared to their younger counterparts (≥ 80 years, n = 3, 9.4% vs. 18-64 years, n = 0, 0.0%; 65-79 years, n = 0, 0.0%; p < 0.001), while no differences in 90-day mortality or 30-day readmission were observed. After surgery, a significant decrease in C-reactive protein levels and leukocytes and amelioration of motor scores were observed in all the groups. Of note, older age (> 65 years), presence of comorbidities, and poor preoperative neurological condition were significant predictors of mortality. Surgical management led to significant improvements in laboratory and clinical parameters in all age groups. However, older patients are prone to multiple risks, requiring meticulous evaluation before surgery. Nevertheless, the risk profile of younger patients should not be underestimated. The study has the limitations of a retrospective design and small sample size. Larger randomized studies are warranted to establish the guidelines for the optimal management of patients from every age group and to identify the patients who can benefit from solely conservative management.

Cervical Epidural Abscess: A Blind Spot for Postmortem Computed Tomography

ABSTRACT

Spinal epidural abscess is an uncommon condition, which may have serious complications, including neurological sequelae and death. Classical symptoms include spinal pain, fever, and neurological deficit; however, diagnosis is difficult and requires a high degree of clinical suspicion. Antemortem magnetic resonance imaging (MRI) scanning is the gold-standard diagnostic tool. Computed tomography (CT) is less sensitive and as such, postmortem CT may miss the diagnosis. We report a case of Staphylococcus aureus cervical epidural abscess presenting as neck pain and causing flaccid paralysis and subsequently death. Antemortem MRI showed a small epidural collection, spinal cord edema, and fluid in the adjacent cervical disc and facet joints; however, these findings could not be appreciated on postmortem CT. Postmortem examination, guided by the antemortem imaging, was able to confirm a cervical spinal epidural abscess; however, similar deaths may occur before medical presentation. This case demonstrates a limitation of postmortem imaging in diagnosing spinal epidural abscess and highlights that such cases may be missed.

Invasive Fusobacterium Infections in Children: A Retrospective Multicenter Study

BACKGROUND

The past decade has witnessed a rise in Fusobacterium infections. This study aimed to describe the epidemiology, clinical and demographic characteristics and outcomes associated with Fusobacterium infections in hospitalized children in central Israel.

METHODS

We retrospectively analyzed the medical records of children <18 years old who had been admitted with a diagnosis of invasive Fusobacterium infection (IFI) between January 2010 and April 2020. Clinical, laboratory and microbiologic data were retrieved. IFI diagnosis was based upon microbiological identification in any specimen by culture or by 16S ribosomal RNA polymerase chain reaction.

RESULTS

Fifty-one children (26 boys) with a median age of 3 years (range, 5-16 years) were included. Hospitalizations for IFI increased from 19 of 100,000 admissions between 2010 and 2015 to 50 of 100,000 between 2016 and 2020, representing a 2.5-fold increase. Most of the infections were from an otogenic source (n = 28, 55%) followed by an oropharyngeal/respiratory source (n = 21, 41%). The most common complications were subperiosteal and epidural abscesses (41% and 37%, respectively). Thrombosis was diagnosed in 11 children, 10 of whom had sinus vein thrombosis. All had an otogenic source. Children with otogenic compared with all other infection sources were significantly younger (median age of 1.9 vs. 3 years; P < 0.001). Forty-seven children (92%) underwent a surgical intervention. All patients survived, one with neurologic sequelae.

CONCLUSIONS

The admissions for IFI in children increased 2.5-fold during the last decade. The most common source is otogenic, especially among younger children, and it is associated with high complication rates. Current management, including combinations of antibiotics and surgical interventions, leads to favorable outcome.

Rare Presentation of Meningitis Due to Lumbar Facetal Septic Abscess: A Case Report

CASE

An elderly obese woman with comorbidities presented with acute-onset altered sensorium. She was diagnosed with meningitis and started on empirical antibiotics. She became oriented after 48 hours and mentioned that she had severe low backache in the previous week. Examination revealed bilateral lower limb weakness. Magnetic resonance imaging showed L3-L4 lumbar facetal abscess (LFA) with epidural extension. Posterior instrumented decompression was performed. Tissue culture grew Enterococcus, and the patient was administered vancomycin and linezolid. At 3 months, there was complete neurological recovery, and she was normal at the 1-year follow-up.

CONCLUSION

This report highlights the rare presentation of LFA complicating meningitis and its treatment.

Acute Symptomatic Seizures in Critically Ill Patients with COVID-19: Is There an Association?

Background

The coronavirus disease of 2019 (COVID-19) emerged as a global pandemic. Historically, the group of human coronaviruses can also affect the central nervous system leading to neurological symptoms; however, the causative mechanisms of the neurological manifestations of COVID-19 disease are not well known. Seizures have not been directly reported as a part of COVID-19 outside of patients with previously known brain injury or epilepsy. We report two cases of acute symptomatic seizures, in non-epileptic patients, associated with severe COVID-19 disease.

Case Presentations

Two advanced-age, non-epileptic, male patients presented to our northeast Ohio-based health system with concern for infection in Mid-March 2020. Both had a history of lung disease and during their hospitalization tested positive for SARS-CoV-2. They developed acute encephalopathy days into their hospitalization with clinical and electrographic seizures. Resolution of seizures was achieved with levetiracetam.

Discussion

Patients with COVID-19 disease are at an elevated risk for seizures, and the mechanism of these seizures is likely multifactorial. Clinical (motor) seizures may not be readily detected in this population due to the expansive utilization of sedatives and paralytics for respiratory optimization strategies. Many of these patients are also not electrographically monitored for seizures due to limited resources, multifactorial risk for acute encephalopathy, and the risk of cross-contamination. Previously, several neurological symptoms were seen in patients with more advanced COVID-19 disease, and these were thought to be secondary to multi-system organ failure and/or disseminated intravascular coagulopathy-related brain injury. However, these patients may also have an advanced breakdown of the blood–brain barrier precipitated by pro-inflammatory cytokine reactions. The neurotropic effect and neuroinvasiveness of SARS-Coronavirus-2 have not been directly established.

Conclusions

Acute symptomatic seizures are possible in patients with COVID-19 disease. These seizures are likely multifactorial in origin, including cortical irritation due to blood–brain barrier breakdown, precipitated by the cytokine reaction as a part of the viral infection. Patients with clinical signs of seizures or otherwise unexplained encephalopathy may benefit from electroencephalography monitoring and/or empiric anti-epileptic therapy. Further studies are needed to elucidate the risk of seizures and benefit of monitoring in this population.

Evaluating new paralysis, mortality, and readmission among subgroups of patients with spinal epidural abscess: A latent class analysis

Background

Spinal epidural abscess (SEA) is increasing in incidence; this not-to-miss diagnosis can cause significant morbidity and mortality, particularly if diagnoses are delayed. While some risk factors for SEA and subsequent mortality have been identified, the SEA patient population is clinically heterogeneous and sub-populations have not yet been characterized in the literature. The primary objective of this project was to identify characteristics of subgroups of patients with SEA. The secondary objective was to identify associations between subgroups and three clinical outcomes: new onset paralysis, in-hospital mortality, and 180-day readmission.

Methods

Demographics and comorbid diagnoses were collected for patients diagnosed with SEA at an academic health center between 2015 and 2019. Latent class analysis was used to identify clinical subgroups. Chi-squared tests were used to compare identified subgroups with clinical outcomes.

Results

We identified two subgroups of patients in our analysis. Group 1 had a high rate of medical comorbidities causing immunosuppression, requiring vascular access, or both. Group 2 was characterized by a high proportion of people with substance use disorders. Patients in Group 2 were more likely to be readmitted within 6 months than patients in Group 1 (p = 0.03). There was no difference between groups in new paralysis or mortality.

Discussion

While prior studies have examined the SEA patient population as a whole, our research indicates that there are at least two distinct subgroups of patients with SEA. Patients who are younger, with substance use disorder diagnoses, may have longer hospital courses and are at higher risk of readmission within six months. Future research should explore how to best support patients in both groups, and additional implications for subgroup classification on health outcomes, including engagement in care.

Spinal epidural abscess associated with an epidural catheter in a woman with complex regional pain syndrome and selective IgG3 deficiency: A case report

RATIONALE

Continuous epidural infusion of local anesthetic may be an alternative to sympathetic blocks in refractory cases of complex regional pain syndrome (CRPS). Spinal epidural abscess (SEA) is a well-known complication associated with this technique, especially in patients with immune deficiencies. We herewith report a cervical SEA associated with an epidural catheter in a woman with CRPS and selective IgG3 subclass deficiency.

PATIENT CONCERNS

Severe pain interfering with activities of daily living.

DIAGNOSIS

Complex regional pain syndrome type-1 with involvement of upper extremity.

INTERVENTIONS

The patient underwent inpatient epidural infusion for management of left upper extremity CRPS. Her history was notable for previous left shoulder injury requiring numerous surgical revisions complicated by recurrent shoulder infections, and selective IgG3 deficiency. She received antibiotic prophylaxis and underwent placement of a C6-C7 epidural catheter. On day 5, she became febrile. Neurological examination remained unchanged and an MRI demonstrated acute fluid collection from C3-T1. The following day she developed left arm weakness and was taken for emergent cervical decompression. Intraoperative abscess cultures were positive for Pseudomonas aeruginosa.

OUTCOMES

Postoperatively, the patient's neurological symptoms and signs improved.

LESSONS

Patients with selective IgG3 deficiency who are being considered for epidural catheterization may benefit from expert consultation with infectious diseases specialist. A history of recurrent device- or tissue-related infections should alert the clinician to the possible presence of a biofilm or dormant bacterial colonization. Close monitoring in an ICU setting during therapy is recommended. In case of early signs of infection, clinicians should have a high suspicion to rule out a SEA in immunocompromised patients.

Nocardial spinal epidural abscess with lumbar disc herniation: A case report and review of literature

RATIONALE

Nocardial spinal epidural abscess is rare. The diagnosis is often difficult to make and, if delayed, poses a high risk of long-term disability. Nocardial spinal epidural abscess with severe lumbar disc herniation has not previously been reported.

PATIENT CONCERNS

A 50-year-old man presented with progressive lumbago and leg pain for 6 weeks after receiving acupuncture therapy, and then the patient suddenly occurred urine retention after walking.

DIAGNOSES

Clinical examination revealed sign of cauda equina syndrome. Magnetic resonance imaging (MRI) revealed a Lumbar(L)4 to L5 disc herniation, L3 to Sacrum(S)1 epidural abscess, and L2 to S1 paravertebral abscess. The causative organism was Nocardia farcinica.

INTERVENTIONS

An urgent paravertebral abscess debridement and right L4 to L5 laminectomy were performed. Simultaneously, the disc tissue protruding into the spinal canal was removed, as well as irrigation and drainage. And antimicrobial treatment was continued for 12 months.

OUTCOMES

Fortunately, the patient was able to walk with a cane and urinate autonomously without a catheter, although this remained difficult 7 days after surgery. After 1 year of treatment, the patient has recovered completely and returned to work.

LESSONS

Nocardial spinal epidural abscess with severe lumbar disc herniation is extremely rare. Pain from spinal degenerative diseases often masks the early symptoms of spinal infection. It's worth noting that invasive treatment of spine is a way of causing spinal nocardial infection.

The time-sensitive challenge of diagnosing spinal epidural abscess in the emergency department

Spinal epidural abscess (SEA) is a rare but devastating condition. Entry of infectious contents into the epidural space occurs via contiguous infected tissue, hematogenous spread, or iatrogenic inoculation. Traditionally, emergency providers are taught to assess for the "classic triad" of spinal pain, fever, and neurological deficits, but this constellation of findings is seen in only 10-15% of cases. Delays in diagnosis and treatment of this condition directly correspond to worse, and often debilitating, outcomes for these patients. This review will demonstrate the challenges of diagnosing SEA, describe key diagnostic pitfalls, and present a model and framework for its evaluation. The authors conducted a systematic review in PubMed and Google Scholar for articles describing the emergency medicine evaluation and management of spinal epidural abscess dating from 1996 to 2016. Of the initial 219 articles found, 18 articles were selected based on their relevancy to emergency medicine. Lower back pain is a common chief complaint, whereas SEA is a rare condition and may not be anticipated. The "classic triad" of SEA symptoms presents infrequently. Moreover, the early symptoms of back pain and fever are non-specific, and patients seek medical attention at varying stages of disease progression. Once the more conspicuous and wide-ranging neurological symptoms develop, they are often irreversible. In fact, final outcomes correlate with the severity and duration of symptoms before surgery. Furthermore, discovering these late neurological symptoms can be particularly difficult in bed-bound and chronically ill patients. MRI is the best diagnostic imaging tool for SEA. Early diagnosis is the major prognostic factor for favorable outcome of SEA, and yet, making this diagnosis in the emergency department (ED) has proved challenging. Shifting from a "classic triad" screening to a risk factor-based model of evaluation represents the current optimal strategy for diagnosing SEA. An algorithm incorporating the most recent data is provided.

Emergency 1-stage anterior approach for cervical spine infection complicated by epidural abscess

It was a retrospective analysis.The aim of the study was to explore the safety and reliability of emergency 1-stage radical debridement and reconstruction using titanium mesh filled with autologous bone for patients with cervical spine infection complicated by epidural abscess.At present, cervical spine infection complicated by epidural abscess is known as a severe spine disease. Recently, case report of this disease is showing quite an increasing tendency, particularly in economically undeveloped areas and countries. Regarding the treatment of this disease, 1-stage radical debridement and reconstruction has been widely adopted; however, emergency 1-stage anterior approach surgery without medication is considered as a relatively taboo, since it is generally acknowledged that such operation would possibly cause unexpected infection. Nevertheless, regular elective surgery may require longer time for preparation. In addition, long hour compression and stimulation of the abscess may leave the patients with irreversible spinal neural impairment. However, our department has finished 14 cases of cervical spine infection complicated with epidural abscess without 1 single case of postoperative infection.A retrospective study was conducted on 14 patients (9 males and 5 females; average age 57.4 years) who were diagnosed with cervical spine infection complicated by epidural abscess from January 2005 to December 2014. All the patients were admitted to hospital with varying degrees of neurological function losses, and then underwent 1-stage anterior focal debridement and reconstruction using titanium mesh within 24 hours after admission. They received postoperative standard antibiotic chemotherapy for 10 to 12 weeks. They were followed up for 18 to 36 months, an average of 27.4 months. X-ray, computed tomography (CT), and MRI (magnetic resonance imaging (MRI) were used to determine the fusion state and vertebral stability. American Spinal Injury Association (ASIA) international standards for neurological classification were adopted, white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were evaluated to infection activity, and Japanese Orthopaedic Association (JOA) and visual analog scale (VAS) criteria were used to judge clinical efficacy.All the 14 patients had no postoperative spread of infection. No recurrence of infection was found during the last follow-up. ASIA grade, VAS score, and JOA score were significantly improved (P < .05) after the operation. WBC, ESR, and CRP became normal after the operation (P < .05). Postoperative follow-up imaging results showed no significant loss of cervical curvature, collapse of the grafted bone or implant displacement but good spinal canal volume.Emergency 1-stage radical debridement and reconstruction using titanium mesh filled with autologous bone, combined with antibiotic chemotherapy, is a safe and effective surgical therapy for cervical infection complicated by epidural abscess.

Characteristics of and risk factors for severe neurological deficit in patients with pyogenic vertebral osteomyelitis: A case-control study

Severe neurological deficit (SND) is a rare but major complication of pyogenic vertebral osteomyelitis (PVO). We aimed to determine the risk factors and the variables associated with clinical improvement for SND during PVO.This case-control study included patients without PVO-associated SND enrolled in a prospective randomized antibiotic duration study, and patients with PVO-associated SND managed in 8 French referral centers. Risk factors for SND were determined by logistic regression.Ninety-seven patients with PVO-associated SND cases, and 297 controls were included. Risk factors for SND were epidural abscess [adjusted odds ratio, aOR 8.9 (3.8-21)], cervical [aOR 8.2 (2.8-24)], and/or thoracic involvement [aOR 14.8 (5.6-39)], Staphylococcus aureus PVO [aOR 2.5 (1.1-5.3)], and C-reactive protein (CRP) >150 mg/L [aOR 4.1 (1.9-9)]. Among the 81 patients with PVO-associated SND who were evaluated at 3 months, 62% had a favorable outcome, defined as a modified Rankin score ≤ 3. No factor was found significantly associated with good outcome, whereas high Charlson index [adjusted Hazard Ratio (aHR) 0.3 (0.1-0.9)], low American Spinal Injury Association (ASIA) impairment scale at diagnosis [aHR 0.4 (0.2-0.9)], and thoracic spinal cord compression [aHR 0.2 (0.08-0.5)] were associated with poor outcome. Duration of antibiotic treatment was not associated with functional outcome.SND is more common in cervical, thoracic, and S. aureus PVO, in the presence of epidural abscess, and when CRP >150 mg/L. Although neurological deterioration occurs in 30% of patients in early follow-up, the functional outcome is quite favorable in most cases after 3 months. The precise impact of optimal surgery and/or corticosteroids therapy must be specified by further studies.

Concomitant epidural and subdural spinal abscess: a case report

BACKGROUND CONTEXT

Spinal subdural abscess (SSA) is a rare occurrence for which the management typically involves open surgical removal and washout.

PURPOSE

This case report aims to review the literature and discuss the management of patients with SSA.

STUDY DESIGN

We present a case of a 33-year-old female who presented with a spinal epidural abscess and concurrent SSA. She presented in the context of intravenous (IV) drug use, back pain, and generalized lower extremity weakness.

METHODS

The literature was reviewed with a focus on modern treatment options for SSA. Our patient was managed with IV antibiotics, and separate laminectomies and washouts for both lesions.

RESULTS

The patient recovered well with return of neurologic function and normalization of infection markers. The review of the literature resulted in a management flowchart that will help direct treatment of SSA.

CONCLUSIONS

The literature suggests that in a patient with a definitive diagnosis of SSA, limited surgical management and IV antibiotics are the mainstay of treatment in a patient with a decline in neurologic function. There may be a role for expectant management in the absence of diagnostic imaging or the neurologically stable patient.

Immediate resolution of severe bullous chronic regional pain syndrome with onset of spinal paralysis

Complex regional pain syndrome (CRPS) is an incompletely understood disorder characterized by progressive regional pain and sensory changes, with fluctuating cutaneous edema and erythema. We describe a patient with a rarely reported severe bullous CRPS variant on the left lower extremity, which resolved immediately upon developing spinal paralysis.

Hip pain and cauda equina syndrome

Acute cauda equina syndrome secondary to a spinal epidural abscess as a result of a psoas abscess is very uncommon. We report the case of a 64-year old with a 6-day history of left hip pain, which progressively worsened until she presented to the emergency department with systemic infective symptoms and classical acute cauda equina syndrome. A good clinical outcome was achieved by urgent posterior decompression, followed by CT-guided drainage of the psoas abscess and appropriate antibiotic treatment.

Paediatric tubercular spinal abscess involving the dorsal, lumbar and sacral regions and causing spinal cord compression

Tubercular spinal localization is very rare (5%) in paediatric age. We report the unusual case of a child with a history of bacillus Calmette-Guerin vaccination who presented with lymphadenitis in the absence of pulmonary involvement. Despite appropriate anti-tubercular therapy, the patient developed spinal tuberculosis with cord compression. Urgent surgical decompression was performed: laminectomy was done at D3-D5 levels and the higher abscess was then flushed using a catheter, decompressing the cauda equina. Our findings suggest that diagnosis of tuberculosis should be considered even in light of anamnestic vaccination at birth, and that surgical treatment should be rapidly provided in the event of spinal cord compression to avoid devastating sequelae.

Citrobocter kasori spinal epidural abscess: a rare occurrence

Pyogenic spinal epidural abscess Is an uncommon Infectious occurrence. Clinical prospects of pyogenic spinal epidural abscess are graver if not promptly diagnosed and treated appropriately. A case of spinal epidural abscess has been presented with sinus tract formation at L4-L5 level, of pyogenic aetiology that progressed to paraplegia over the course of the disease. MRI pointed towards an epidural abscess extending from T12 vertebral level to S1 vertebral level. Surgical decompression in the form of laminectomy and evacuation of pus was done and antibiotics were given according to culture and sensitivity. Histopathological analysis revealed the acute suppurative nature of the abscess. Citrobacter kasori was isolated on pus culture. Pyogenic epidural abscess with causative organism being Citrobacter kasori has least been documented.

Acute quadriplegia after interscalene block secondary to cervical body erosion and epidural abscess

Although the incidence of neurological complications after shoulder surgery with regional anesthesia remains low but serious negative outcomes have been reported in the literature. Here we report a case of acute quadriplegia secondary to cervical epidural abscess and possible neck manipulation.

Klebsiella pneumoniae Spinal Epidural Abscess treated conservatively: case report and review

Spinal infections are rare but potentially life-threatening disorders. A high level of clinical suspicion is necessary for rapid diagnosis and treatment initiation. The treatment combines both antibiotics and surgical intervention in the vast majority of cases. The authors report the case of a 84-year old female patient with a three week history of persistent lumbar back pain radiating to both thighs following a lower respiratory tract infection. She had lumbar spine tenderness but no neurological compromise. Her inflammatory markers were elevated and lumbar spine magnetic resonance imaging revealed L4-L5 spondylodiscitis with spinal epidural abscess. Blood cultures isolated Klebsiella pneumoniae and, since she was neurologically stable, conservative treatment with two-week intravenous gentamicin and eight-week intravenous ceftriaxone was initiated with positive inpatient and outpatient evolution.

Spondylodiscitis complicated by an epidural abscess and meningitis caused by Bacteroides fragilis

Bacteroides fragilis is a rare causative agent of spondylodiscitis. The pathophysiology of B. fragilis in spondylodiscitis remains largely unclear because of its rare occurrence. We herein report a case of spondylodiscitis complicated by an epidural abscess and meningitis; B. fragilis was detected in the blood of the patient. Moreover, the patient had a splenic abscess that was confirmed on magnetic resonance imaging. The patient completely recovered with antimicrobial therapy alone.

Single-stage posterior debridement and single-level instrumented fusion for spontaneous infectious spondylodiscitis of the lumbar spine

Spontaneous infectious spondylodiscitis (SIS) is an uncommon condition. The purpose of this retrospective study of 10 adult patients (6 males and 4 females, average age 52 years), all with lumbar SIS and epidural abscess, was to analyze the efficacy of single-stage posterior debridement plus single-level interbody grafting with autologous bone, and transpedicular screw-rod instrumentation. The mean follow-up period was 43 months, with a minimum of 30 months. The back pain was relieved within 3 to 8 days after surgery. Neurologic deficits, present in 5 cases, all improved. Solid fusion was achieved at 6 months in all 10 cases. The mean VAS for pain improved from 7.5 to 1.6, the mean Oswestry Disability Index from 57.8% to 8.1%. The mean physical component of SF-36 (PCS) improved from 32.4% to 54.7%, the mean mental component of SF-36 (MCS) improved from 33.8% to 57.2%. All these changes were significant (p < 0.001). No recurrence of infection was noted. The outcome was quite satisfactory in terms of fusion rate and quality of life.

A rare etiology of cauda equina syndrome

Fungal infections of the spine are very rare and usually seen in immunocompromised patients. Acute cauda equina syndrome presenting in an immunocompetent patient is usually due to a prolapse of the intervertebral disc. Infective pathology caused by Mycobacterium tuberculosis with epidural collection can also have a similar presentation. We present a case of spinal epidural abscess caused by Aspergillus fumigatus, presenting as acute cauda equina syndrome. To the best of our knowledge, spinal aspergillosis presenting as cauda equina syndrome in an immunocompetent patient has not been reported before in the English-language based medical literature. Surgical decompression with antifungal treatment with oral itraconazole yielded a good recovery.

[Syndroma caudae equinae of rare etiology]

The results of treatment patients suffering from syndroma caudae equinae (SCE) are not generally satisfactory. The authors decided to evaluate occurrence according to etiology and permanent consequences after treatment in patients that were treated at the Department of Neurosurgery P. J. Safarik University Hospital in Kosice during 12 years (1996-2007). 95 patients from the 101 members file had SCE caused by disc herniation or spinal stenosis. Rare etiology of SCE was found in the six cases: three had traumatic origin, one spinal epidural abscess, one tumor. SCE developed after surgery of intervetebral disc herniation in one patient. Patients underwent control examination or answered by a questionnaire one year from the beginning of SCE or later. Three patients with traumatic SCE had the moderate residual problems. One patient suffered from intermittent pain, perianogenital hypesthesia had two patients, light motor deficit another one. One patient needs to use increased abdominal pressure for urination. Nobody from this subgroup had sexual difficulties or problems with anal spincters' control. The result of treatment patient with SCE caused by spinal epidural abscess was unfavourable. Permanent pain, perianogenital hypesthesia, hard motor deficit and loss of sexual functions persisted. Patient with oncological SCE had deficit in every traced signs. Similar clinical picture was in a patient with postoperative SCE, but residual deficit was moderate.

Cervical epidural abscess presenting with Brown-Sequard syndrome in a patient with type 2 diabetes

An 80-year-old woman with type 2 diabetes was admitted due to right-handed muscle weakness. The patient presented with Brown-Sequard syndrome, with complete paralysis of the right lower limb along with a loss of pain and temperature sensations in the left lower limb. Magnetic resonance imaging revealed a cervical epidural abscess, and accompanying edema or inflammation of the right side of the spinal cord at the C5 level. She underwent drainage and evacuation of the spinal abscess, followed by intravenous antibiotic administration. These interventions ameliorated the neurological deficits. The present case suggests the importance of epidural abscess as a rare pathogenetic cause of Brown-Sequard syndrome in type 2 diabetes.

Nontraumatic retropharyngeal abscess complicated by cervical osteomyelitis and epidural abscess in post-Katrina New Orleans: four cases

Most retropharyngeal abscesses, including iatrogenic cases, are caused by trauma. Nontraumatic retropharyngeal abscesses usually occur secondary to infection of the retropharyngeal lymph nodes. Because these particular nodes usually disappear by the age of 4 or 5 years, a nontraumatic retropharyngeal abscess in an adult is extremely rare. When they do occur in adults, they are generally seen in immunocompromised patients and in intravenous drug abusers. Left untreated, a retropharyngeal abscess can lead to rare and fatal complications such as cervical osteomyelitis, epidural abscess, and discitis. Retropharyngeal abscesses can be diagnosed with a thorough history of risk factors, an examination for neurologic deficits, and radiologic studies, particularly magnetic resonance imaging. Treatment involves intravenous antibiotic therapy and surgical drainage. During follow-up, it is important to closely monitor the results of clinical neurologic examinations and weekly determinations of the C-reactive protein level and erythrocyte sedimentation rate in order to assess the response to therapy. We report 4 cases of nontraumatic retropharyngeal abscess complicated by cervical osteomyelitis and epidural abscess that were seen in New Orleans within 3 years of Hurricane Katrina, which struck the U.S. Gulf Coast in August 2005.

Fever, pain, and a limp: a case of a psoas and spinal epidural abscess caused by methicillin-resistant Staphylococcus aureus in a diabetic patient

Psoas and spinal epidural abscesses are rare conditions that are infrequently found occurring simultaneously in the same patient. This case presents an 18-year-old female with diabetes mellitus who presented with fever and leg pain. Blood and urine cultures were positive for methicillin-resistant Staphylococcus aureus. A CT scan of the abdomen showed a large psoas abscess with loculations extending and involving the spinal canal. The abscesses were drained and the patient completed a 6-week course of intravenous antibiotics with remarkable improvement of her clinical condition. The diagnosis of psoas and epidural abscesses is difficult and can be overlooked or delayed as a result of their vague clinical manifestations and their rarity, which leads to a lack of clinical suspicion.

Cardiac decompensation in a patient with Eisenmenger syndrome undergoing T5-T7 levels laminectomy in the sitting position

Although several different anesthetic techniques have been employed for noncardiac surgery in Eisenmenger syndrome (ES), the best anesthetic technique is still controversial. A17-year-old male with ES and an epidural abscess at the T5- T7 levels was scheduled to undergo laminectomy in the sitting position. Anesthesia was induced by ketamane and maintained with an opioid-isoflurane technique. A few minutes after extubation, respiratory distress appeared and the patient was reintubated. He was transferred to the intensive care unit (ICU) and maintained on spontaneous intermittent mandatory ventilation and pressure support for 24 hours, and discharged fully recovered on the 4th postoperative day. To our knowledge this is the first case where the sitting position has been adopted for evacuation of an epidural abscess at the T5-T7 levels in a patient with ES. We recommend late extubation and an overnight observation in the ICU for such patients to prevent dangerous sequelae.

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.