Epidural abscess concomitant w”>Case Report

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American Journal of Emergency Medicine

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PanSpinal epidural abscess concomitant with meningitis

Abstract

Panspinal epidural abscess is an extremely Rare condition that can potentially lead to major permanent Neurological deficits if treatment is delayed or suboptimal. Most patients with spinal epidural abscess have a short segment of vertebrae involved and classically present with fever, low back pain, and focal neurologic deficit. In severe cases, meningitis and septic shock may occur and lead to death. Therefore, the condition requires prompt recognition and proper intervention. Herein, we report the case of a 41-year-old diabetic man who presented at our hospital with the symptoms of headache, quadri- plegia with respiratory distress and low back pain. Panspinal epidural abscess and meningitis were diagnosed by carrying out detailed neurologic examinations and neuroimaging studies, which expedited the correct diagnosis and treatment.

A 41-year-old man had type 2 diabetes mellitus and did not receive regular medical treatment for 2 years. He had low back pain

for 1 week and received analgesics but the drugs did not have a significant effect. He was referred to our hospital for progressive deterioration of clinical symptoms associated with headache, weak- ness in all four limbs and shortness of breath. On examination, he was found to have fever as high as 40.1?C, tachypnea with use of accessory muscles and clear breathing sound, and tachycardia without systolic or diastolic murmur on chest auscultation. Neurologic examinations revealed quadriplegia with muscle power grade 0 (Medical Research Council Scale) areflexia in all four limbs with bilateral flexor plantar responses. Nuchal rigidity was present with obvious meningeal sign and Lhermitte’s sign. Severe knocking tenderness was observed with percussion on the whole back. His blood pressure, heart rate and respiratory rate were 96/72 mm Hg, 126 beats/min and 35 breaths/ min, respectively.

Blood tests showed leukocytosis with band neutrophils (up to 34.6%) predominating and hypoxemia. No ketoacidosis was found in

Fig. 1. A, Sagittal T2-weighted image of the cervical spine, the arrows indicate a thick layer of fluid collection posterior to the spinal cord (thoracic and lumbar spine not shown). B, Sagittal contrast-enhanced T1-weighted image, the arrows indicate dural enhancement extending to the posterior fossa. C, Follow-up contrast-enhanced T1-weighted image of the cervical spine demonstrates decreased amount of fluid collection with residual dural enhancement.

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the urine or serum. Blood culture yielded oxacillin-resistant Staph- ylococcus capitis. Magnetic resonance imaging of the brain and spine revealed a thick layer of fluid collection posterior to the spinal cord with dura enhancement extending to the posterior fossa (Fig. 1A-C). The patient was diagnosed with panspinal epidural abscess and meningitis. He received intravenous antibiotic treatment initially and had significant improvement of neurologic deficit and was soon weaned from mechanical ventilation support. The treatment course was given for 4 weeks, and treatment was then shifted to oral regimens based on culture results, which was followed by rehabili- tation programs.

Spinal epidural abscess is a rare debilitating disease that can result in serious morbidity and mortality. It occurs commonly in short spinal segments; mostly involving 3 or 4 spinal vertebrae [1]. Panspinal epidural abscess is extremely rare and there have been few case reports to the best of our knowledge. The risk factors include a variety of immunocompromised conditions such as diabetes mellitus, alcoholism, AIDS, renal failure, cancer, and steroid usage [2]. The most common symptoms of spinal epidural abscess include back pain, fever and neurologic deficits. Respiratory distress with elevated diaphragm usually suggests a spinal root lesion above the third to fourth cervical root. Staphylococcus aureus accounts for two-thirds of cases [1,2]. Coagulase-negative staphylococci, such as S epidermidis and S capitis, which was found in our case, are rarely the culprits. The administration of appropriate antibiotics should be carried out as soon as blood has been collected for testing. The patient refused Surgical debridement and decompression since the neurologic deficit improved gradually, especially in his upper limbs, and he successfully was weaned from the ventilator. Emergent Decompressive laminectomy is not considered for patients with panspinal infection [2].

A detailed neurologic examination must be done accurately to

identify the level of neurologic deficit and whole-spine screening with magnetic resonance imaging should be arranged in such

cases. This case highlights the importance of early accurate diagnosis and Optimal treatment by emergency medicine physi- cians to prevent the devastating conditions of septic shock and evolution of meningitis.

Wen-Sou Lin MD

Department of Neurology Kaohsiung Armed Forces General Hospital National Defense Medical Center

Taipei, Taiwan

Hung-Wen Kao MD Department of Radiology Tri-Service General Hospital

National Defense Medical Center

Taipei, Taiwan

Chun-An Cheng MD Department of Neurology Tri-Service General Hospital

National Defense Medical Center

Taipei, Taiwan E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.03.013

References

1. Gorchynski J, Hwang J, McLaughlin T. A methicillin-resistant Staphylococcus aureus- positive holospinal epidural abscess. Am J Emerg Med 2009;27:514.
2. Darouiche RO. Spinal epidural abscess. N Engl J Med 2006;355:2012-20.