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We describe a rare case of spinal epidural abscess, which resulted from a colospinal fistula that developed as a complication of previous surgical resection and radiotherapy for rectal carcinoma. The patient's clinical course and the imaging features of colospinal fistula are described, along with a brief review of the literature.
Conversion disorders are symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or medical condition. The psychological symptoms associated with the medical condition must be preceded by conflict or other stressors. We present an individual who developed conversion disorder and paraplegia secondary to a sterile epidural abscess near the tip of her surgically implanted, epidural morphine infusion pump. She manifested at varying times both transient bilateral blindness and pseudoseizures consistent with a diagnosis of conversion disorder. Neurological evaluation for seizure activity and meningitis were negative. The etiology of the sterile epidural abscess remained unknown. The essential features of conversion disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, are discussed. Treatment of patients diagnosed with conversion disorder remains primarily supportive, with the focus on consistency and behavioral management. Extreme caution is suggested in regards to further investigations.
A case of tricuspid valve endocarditis with spinal epidural abscess caused by Actinobacillus actinomycetemcomitans is reported in a 74-year-old male with an endocardial pacemaker. Despite antibiotic treatment, removal of the endocardial wire was necessary for recovery.
A case of epidural lipomatosis in a 49-year-old man presenting with paraparesis, midthoracic pain, and Staphylococcus aureus pneumonia is reported. The patient had been on low dose corticosteroid therapy for 7 years for rheumatoid arthritis. The clinical and myelographic findings suggested a diagnosis of epidural abscess, but the only abnormality discovered at operation was abundant fatty tissue in the dorsal epidural space significantly compressing the spinal cord, and this was partially removed. Postoperative neurological improvement suggested that the lipomatosis was responsible for the spinal cord compression and dysfunction. If this diagnosis had been suspected, it might have been confirmed by magnetic resonance imaging or postmyelography computed tomographic scanning. With such a diagnosis, an alternative treatment could have been to decrease the steroid dose, observe for clinical improvement, and perhaps avoid operation.
P. mirabilis and P. vulgaris are the two wellknown species in the genus Proteus. P. myxofaciens and P. penneri are recent additions to the genus. We isolated P. penneri from the pus of a patient with suppurative otitis media and an epidural abscess. The characteristics of the organism, including morphology, staining, physiology and biochemistry, were studied. Clinical microbiological laboratories should suspect P. penneri in the case of as Proteus strain that is negative for indole, salicin and esculin, but otherwise resembles P. vulgaris. Proteus penneri, formerly known as Proteus vulgaris indole-negative or as Proteus vulgaris biogroup 1, was named by Hickman et al in 1932. Little information about human infection by this organism is available. In 1982, Hickman and co-workers studied 20 strain of P. penneri which were isolated from clinical specimens (urine, stool, etc.) in the USA. However, its clinical significance, until recently, was unknown. We isolated a strain of P. penneri from the pus of a patient with suppurative otitis media and an epidural abscess on June 10 and 15, 1989. This paper concerns the problems encountered in identifying this organism and its clinical significance.
The diagnosis of spinal epidural abscess is often delayed until the onset of rapidly deteriorating neurologic function. To illustrate the variability of presenting symptoms with this disease, two contrasting cases are presented. The pathogenesis of the disorder, bacterial etiologies, diagnostic modalities, and treatment alternatives are discussed.
Acute otitis media with complications is a persistent problem in the modern antibiotic era with a relatively high mortality rate. Acute mastoiditis is a serious complication of acute otitis media with potentially grave consequences and the epidural abscess constitutes the commonest of all intracranial complications, arising from middle ear infections. We report two cases of children with acute mastoiditis without evidence of intracranial complication or subperiosteal abscess, in whom the early evaluation with computed tomography (CT) disclosed an unsuspected epidural abscess. Therefore, we stress the use of CT as a rule of thumb for every child with acute mastoiditis.
A 54-year-old female was admitted to our hospital on May 8, 1996, for evaluation of fever and headache. Her cerebrospinal fluid showed elevation of the cell count and total protein. The thoracic and lumbar MRIs revealed abnormal gas occupying the epidural space at the sacral level, and extended as high as 9th thoracic level. The gas spread inside the iliopsoas and paraspinal muscles. Anaerobic bacteria such as Bacteroides fragilis and Peptostreptococcus productus were cultured from the spinal fluid and Bacteroides was also detected from the epidural tissues obtained during laminectomy. The infectious source was decubitus extending around the sacral bone. The combination therapy of debridement with peroxide, catheter drainage of epidural abscess, intravenous and intrathecal antibiotics, and laminectomy presented her good outcome. This is a rare case of anaerobic bacterial spinal abscess, showing epidural and intramuscular gas as a prominent feature.
A 49-year-old drunken man was involved in a motorbike crash. He presented with cervical spine injury and multiple limbs fracture. Neuro-imaging demonstrated disruption of the C5-6 anterior longitudinal ligament, herniation of C3-4 and C5-6 discs, and Th1 compression fracture. The neurological deficits improved after anterior cervical decompression, fusion and fixation. One week later, he suffered from fever and severe upper back pain, and he developed paraplegia subsequently. The following image study disclosed esophageal perforation at the level of Th1 and epidural abscess spreading from levels Th1 to Th5. After proper management and rehabilitation, he achieved good recovery one year later at follow-up. We report the unique case of Th1 fracture with esophageal perforation complicated with spinal epidural abscess. The possible mechanism and the controversy concerning therapy for esophageal perforation are discussed.
Twenty-nine adult patients with spinal epidural abscess (SEA), aged 31-73 years, have been identified over a period of 8 years. The 29 SEA patients included 21 men and eight women with a mean age of 54 years. Initial diagnosis of SEA was made in only 17% of our patients and another 48% of patients were initially suggested of having infection or mass of the spine. Spinal pain and fever were the two most common clinical features shared among our patients. The two most common pathogens were Staphylococcus aureus and Mycobacterium tuberculosis, which were found in 62% of patients. Twenty-seven patients received surgical intervention and antibiotic treatment for SEAs, one of which succumbed to meningitis. Two patients without neurological abnormalities received conservative treatment alone and survived. The number of patients, which showed improvement of symptoms, included all seven patients with neck/back pain without neurologic deficits, all 15 patients with paraparesis, 10 of 13 patients with bladder/bowel dysfunction with or without motor deficits, and none of the five with plegia. Preoperative plegia was identified as a poor prognostic factor, and patients with SEA continue to show high rates of morbidity and mortality. Thus, in order to improve the therapeutic outcome of patients with SEA, early diagnosis and management are mandatory to treat the patients before the deterioration of neurologic deficit occurs.
INTRODUCTION: An epidural spinal abscess is a rare clinical condition which may cause rapid, irreversible neurological deterioration. Usually, the patient presents with back pain in the affected spinal segment, but the condition is rarely considered in the differential diagnosis. CLINICAL CASE: A 57 year old man with no significant clinical history initially consulted complaining of cervicalgia. Some days later, this had worsened and he also had odinophagia, fever and general malaise. A diagnosis of retropharyngeal abscess was made. He was admitted to the Ear, Nose and Throat Department (ENT) and antibiotic treatment started with ceftazidime, vancomycin and clindamycin. Eight hours after admission he complained of paresthesia and subsequently of flaccid tetraparesia. CT and MR showed the presence of a paravertebral mass which extended to the epidural space between the fourth and seventh cervical vertebrae. On suspicion of a retropharyngeal abscess complicated by an epidural spinal abscess we proceeded to emergency operation and drained the prevertebral and epidural pus. On microbiological culture St. aureus was grown. The patient regained the mobility of his limbs. On discharge from hospital he still had paresia of the right leg, although this did not impede walking. CONCLUSIONS: It should not be forgotten that, although rare, one of the causes of spinal compression and neurological deterioration (particularly in a febrile patient) is an epidural spinal abscess. Prompt diagnosis and satisfactory surgical decompression are essential to avoid irreversible neurological sequelae.
The aim of this study was to emphasize the importance of non-surgical treatment for subgroups of patients with spinal epidural abscesses (SEA). From 1988 to 2000, thirty cases of epidural spinal abscesses were retrospectively included in the study. The records and radiological studies were evaluated. Staphylococcus aureus was the most frequent microorganism causing SEA in 18 patients. In 20 patients SEA was secondary to interventional procedures. Predisposing factors were present in 15 cases. Fifty per cent was located in the lumbar region. A total of 22 patients received MRI, which always gave the diagnosis of SEA. Surgical treatment was performed in 20 patients. Conservative treatment with antibiotics was used in 10 patients. Eight patients did not have neurological deficits. One patient was critically ill and another patient was paralysed with an epidural lesion extending over six spinal segments. In all cases, a microorganism was known at the time of diagnosis of ESA. The eight patients without deficits recovered completely following treatment with antibiotics. C-reactive protein was the most reliable inflammatory marker to monitor the effect of the treatment. MRI enables diagnosis of ESA before deficits occur. These can safely be treated with antibiotics if the causative microorganism is known, and the neurological status and laboratory values are monitored. Decompressive surgery is restricted to cases with progressive deficits, when the deficits have lasted for less than 36 h and when the microorganism is not known.
Spinal abscess due to Aspergillus is rare. A young boy with chronic granulomatous disease and aspergillosis of the rib had been treated with antifungal treatment 3 months earlier. The patient presented with a brief history of progressive paraparesis. Imaging showed D9--11 vertebral involvement and destruction of the D10 vertebral body with angulation and a large dorsally placed, multiloculated epidural abscess extending from D6 to L2. There was also extensive granulation anterior to and on either side of the vertebrae. The patient underwent extensive laminectomy and decompression of all the loculi and partial removal of the granulation tissue. Aggressive medical treatment was started. The authors recommend an aggressive surgical and medical approach in such cases of disseminated invasive aspergillosis, even though the result may not be very satisfactory. This report discusses the full clinical profile and management of Aspergillus spinal epidural abscess and emphasizes the need to follow up these cases to detect recurrence and new lesions, even if the patients are on adequate medical treatment. In spite of all efforts, high morbidity and mortality is common in such patients.
Fourteen cases of acute spinal epidural abscess are analysed. Postoperatively 6 recovered completely, 4 patients recovered enough to allow unaided walking, 2 died and 2 who were paraplegic pre-operatively remained so. The purpose of this paper is to remind readers of the existence of this condition and to plead for early diagnosis and prompt surgical treatment.
We present four cases of spinal epidural abscess diagnosed in Clinica Puerta de Hierro between 1982 and 1990. In three cases the localization was thoracic and in one it was lumbar. Fever and vertebral pain were the more constant clinical symptoms. Lumbar punction showed findings in Cerebro-Spinal Fluid compatible with a parameningeal inflammation focus in the three cases it was performed. Diagnosis was established with myelography or Computerized Axial Tomography. Treatment in two cases was laminectomy and systemic antibiotics: and only antibiotics in the other two cases. Evolution was favorable in the patients who underwent surgery, but the patients treated conservatively had a fatal outcome.
A 67-year-old man under hemodialysis treatment developed neck stiffness, fever and conscious disturbances. The patient was infected with Methicilin-resistant Staphylococcus aureus (MRSA) sepsis caused by an infection on a dialysis shunt. On admission, he was diagnosed with bacterial meningoencephalitis and underwent a series of antibiotic chemotherapies. The treatment brought cell count in the cerebrospinal fluid to a subnormal level but his clinical status did not improve. The patient continued to have high level of cerebrospinal fluid protein (898 mg/dl). Cervical MRI demonstrated two abscesses deep in the neck as well as in the epidural region of the cervical spinal cord, from C2 to C5 vertebral levels. Based on these findings, spinal epidural abscess (SEA) was diagnosed. Intensive antibiotic chemotherapy especially targeted for MRSA could eradicate abscesses and improve clinical status. However, persistent high protein level in the cerebrospinal fluid could suggest SEA.
In this report, we describe the appearance of the spinal vertebral body and epidural abscesses in a patient who underwent diffusion-weighted imaging of the spine and CT-guided aspiration of one of the abscesses. The abscesses were hyperintense relative to the surrounding tissues on diffusion-weighted images, and they appeared dark on apparent diffusion coefficient maps; these findings were consistent with those of published reports of the brain and liver.
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