Case Report

Cluster-like headache as an opening symptom of cervical spinal Epidural abscess

Abstract

Many patients with Spinal epidural abscess did not have classic symptoms, and delayed diagnosis may occur. We pre- sent a patient who visited the emergency department for a headache. The pain was twitching and over the left fronto- pariero-occipital area. Left eye lacrimation was found. Erythe- matous change of the skin over left parietooccipital area was also noted. The patient was hospitalized for further evaluation. Cervical epidural abscess was diagnosed when upper limb weakness developed during hospitalization. In conclusion, cervical spine cord lesion should be considered when patients present with unilateral headache, although it is difficult when patients are without other Neurologic manifestations.

Classic symptoms of spinal epidural abscess include fever, spine pain, and neurologic deficits. Many patients of spinal epidural abscess did not have all “classic symptoms” and delayed diagnosis may occur. We present a patient who came to the emergency department (ED) because of a headache. The headache had some characteristics of Cluster headaches. Later, cervical spinal epidural abscess was diagnosed.

A 76-year-old man visited our ED because of progressive headache. He had had hypertension for 3 to 4 years and left eye blindness because of anterior ischemic optic neuropathy. His headache was subacute, mainly located at the left fronto- pariero-occipital area, and had persisted for 5 to 6 days. The pain was twitching with a tingling sensation. Allodynia and hyperalgia were noted at the same area when the headache attacked. The duration lasted nearly all day. He had visited clinics and the headache could only be temporarily reduced by analgesics. He also denied any fever or dehydration episodes. On the day in our ED, he had headache and general weakness. He visited a local medical clinic and was transferred to our ED for help.

At ED, the headache was reported and left eye lacrimation was found. Erythematous change of the skin over the left parieto-occipital area was also noted. Left ptosis was found, but the ptosis had lasted for years according to the patient’s statement. He had no limitation of Extraocular movements, but the corneal reflex and sensation were impaired over his left eye. No obvious weakness in extremities was noted at ED.

brain computed tomography was done and revealed low attenuation at left corona radiate. Laboratory examination included complete blood cell count, alanine aminotransfer- ase, creatinine, sodium, potassium, prothrombin time, and partial thromboplastin time. Anemia (hemoglobin, 10.6 g/dL) and elevated creatinine level (2.2 mg/dL) were found, and other data including white blood cell count (8500/uL) were normal. As for the Severe headache, it was arranged he would be hospitalized for further evaluation.

On day 5 of hospitalization, acute onset of left upper limb proximal weakness developed. Magnetic resonance imaging of brain and sonography of left shoulder were performed, and no abnormality contributing to the symptoms were found. Subsequently, magnetic resonance imaging of cervical spine was performed on day 7 of hospitalization and revealed fusiform low T1W, high T2W with enhanced lesion in posterior Spinal canal at level C2-6 and heterogenous signal intensity in left paraspinal soft tissue C2-6 with heterogenous enhancement consistent with posterior epidural abscess C2-6 (Fig. 1). Cervical epidural abscess was diagnosed. Surgical intervention was performed on day 9 of hospitalization. Headache subsided after the operation and the weakness improved gradually.

This case of cervical spine abscess has radiculopathy and sympathetic nerve involved. Thus, a headache with tearing, facial redness was noted. Accompanied with the patient’s previous ptosis, it had several characteristics of a cluster headache. We reviewed previous studies, and although a variety of neurologic manifestations have been described, cluster-like headache has seldom been reported before. Cluster-like headache has been reported as an opening symptom of cervical cord lesion such as infarction [1]. Our patient was afebrile and had no obvious localized spinal pain initially. White blood cell count was normal. Therefore, the diagnosis of cervical spine epidural abscess was delayed until left arm weakness developed during hospitalization.

Fever, back pain, and neurologic defect are the classic symptoms of spinal epidural abscess. These symptoms do not always occur, and previous studies [2-5] have reported 82% to 100% localized pain, 48% to 67% fever, and 56% to 80% neurologic symptoms. It is not uncommon to have atypical presentation [6,7]. The most common risk factors are diabetes mellitus, trauma, intravenous drug abuse, and alcoholism [2,4]. Our patient had no significant risk factor and this also resulted in difficult diagnosis. Delayed diagnosis [8] of spinal epidural abscess often occurs and affects prognosis. As the

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Fig. 1 Magnetic resonance imaging of cervical spine revealed fusiform low T1W, high T2W with enhanced lesion in posterior spinal canal at the C2-6 level and heterogenous signal intensity in left paraspinal soft tissue C2-6 with heterogenous enhancement consistent with posterior epidural abscess at C2-6.

disease progresses, developing neurologic ministrations may help diagnosis but exacerbate the prognosis.

In conclusion, cervical epidural abscess may present with cluster-like headache as radiculopathy and sympathetic nerve involvement. Although early diagnosis is warranted for spinal epidural abscess, it is still difficult when patients present atypical symptoms.

Kuan-Ting Liu MD Department of Emergency Medicine Kaohsiung Medical university hospital Kaohsiung Medical University

Kaohsiung 807, Taiwan, Republic of China

Chen-San Su MD

Department of Neurology Chang Gung Memorial Hospital- Kaohsiung Medical Center Chang Gung University College of Medicine

Kaohsiung 833, Taiwan, Republic of China E-mail address: [email protected]

doi:10.1016/j.ajem.2008.07.014

References

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