Epidural abscess in a”>Case Report

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American Journal of Emergency Medicine

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American Journal of Emergency Medicine 32 (2014) 1558.e1-1558.e2

Spontaneous Spinal epidural abscess in a 21-month-old child

Abstract

Spontaneous epidural abscess formation is a rare finding in all populations and even more so in the pediatric population. Its rarity and variED presentations often lead to misdiagnosis. We present a pediatric case in which the diagnosis of spontaneous spinal epidural abscess was missed upon initial presentation and subsequently identified at a later visit to the emergency department. Literature suggests utilizing three simple Physical exam findings that may improve the First visit diagnosis of spontaneous epidural abscesses in children. Findings of any two of the following signs should guide the clinician to consider SEA as a possibility prior to discharge: fever, back or neck pain, extremity weakness or inability to walk.

Spontaneous epidural abscess (SEA) formation is a rare finding in all populations and even more so in the pediatric population. This is a true emergency that can have severe life-changing, if not life- threatening, outcomes. Presentation, history, and clinical examination vary widely, and the diagnosis can be easily missed on first presentation. We present a pediatric case in which the diagnosis of SEA was missed upon initial presentation and subsequently identified at a later visit to the emergency department (ED).

A 21-month-old child presented to the ED upon referral from his primary care physician to be evaluated for Septic arthritis. The child had been well up until 4 days prior, when he began to develop fever with no obvious source. At that time, the Pneumocystis carinii pneumonia (PCP) clinically ruled out acute otitis media, and a rapid Streptococcus test was negative. There had been no clinical indication to begin the child on antibiotics. The parents were advised to use antipyretics for Fever control and to return if the patient was not improving. After 3 days with no improvement, the patient returned to the PCP, where he showed clinical signs of septic arthritis vs Transient synovitis. The patient was febrile and refusing to walk. He had no history of any trauma. He was referred to the ED for further workup. Physical examination showed temperature of 39.9 C, pulse rate, 157 beats per minute; respiratory rate, 26 breaths per minute; and oxygen saturation of 97% on room air. He was crying but consolable and nontoxic appearing. His right hip and knee were held in flexion, and there was pain on attempt to straighten his leg. There was no focal tenderness to any portion of his lower extremities. He refused to bear full weight but did allow his toes to gently touch the floor. He was Neurologically intact with no other findings on physical examination. complete blood count and comprehensive metabolic panel (CMP) were unremarkable. erythrocyte sedimentation rate was 96 mm/hour, and C-reactive protein (CRP) was 200.1 mg/L. Ultrasound of the right hip was normal. Magnetic resonance imaging (MRI) of the pelvis showed abscess within the quadrates lumborum on the right with extension into the Spinal canal and epidural abscess formation at the L4 and L5 (Fig. 1). There was no osteomyelitis (Fig. 2). Subsequent MRI of

the brain was negative. The patient underwent right-sided L4, L5, and partial S1 laminectomy with drainage of the abscess. Cultures grew ?-hemolytic streptococcus A. He was discharged on intravenous rocephin for a total of 6 weeks during which time his clinical status returned to baseline.

Spontaneous spinal epidural abscesses are thought to be a rare event, having an incidence rate of less than 1 per 100000 person years in all comers and even more rare in children. Spontaneous spinal epidural abscesses is a true emergency that can result in severe neurologic deficits and is potentially life threatening. Because the initial symptoms of SEA are vague and vary from person to person, the diagnosis is often missed on multiple occasions before definitive diagnosis and treatment. This Delay in diagnosis poses a threat that may have irreversible consequences for the patient. It is imperative that the care provider be familiar with the more common presenta- tions of SEA so that diagnosis and definitive treatment can be provided in a timely manner to prevent irreversible neurologic injury. Abscesses are more common after procedures such as lumbar puncture or spinal surgery, but SEA does not afford the clinician with such a history. It is thought that pediatric SEA occurs mainly through hematogenous spread from illnesses that are common in the pediatric population. These illnesses include but are not limited to acute otitis media, tonsillitis, pharyngitis, etc [1]. The most common bacteria cultured are Staphylococcus aureus, which has been found as the

causative agent in up to 80% of SEA cases [2].

The case presented demonstrates the difficulty in diagnosing this disease on first presentation. There are, however, certain findings that are common to many cases of SEA both in children and adults. Among the most common complaints are Musculoskeletal pain, neurologic deficits such as weakness or inability to walk, and fever. Although hard data are lacking in the pediatric population, one study in adults found 93% (13/14) of patients studied for SEA had initial complaint of musculoskeletal pain in the neck, back, or legs; 71% (10/14) had

Fig. 1. MRI pelvis axial fast spin echo (FSE) T1.

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1558.e2 T.J. Harris, J.P. Seamon / American Journal of Emergency Medicine 32 (2014) 1558.e1-1558.e2

We propose that clinicians use the signs of fever, neck/back pain, and inability to walk/extremity weakness as a guide to identify this time-sensitive disease process earlier with fewer patients needing multiple visits before the diagnosis is made. More studies need to be completed to evaluate the validity of any such claims, but at this time, if a patient presents with 2 or more of these findings as mentioned, there should be a high suspicion for SEA, and further studies such as CBC, CRP, ESR, and MRI may be necessary to rule SEA out or in.

Spontaneous epidural abscess formation in the pediatric popula- tion is a rare event and can easily be misdiagnosed or not diagnosed at all during initial visits to health care providers. Literature suggests using 3 simple physical examination findings that may improve the first visit diagnosis of SEAs in children. Findings of any 2 of the following signs should guide the clinician to consider SEA as a possibility before discharge: fever, back or neck pain, extremity weakness, or inability to walk.

Fig. 2. MRI pelvis sagittal FSE T2.

extremity weakness or difficulty walking; 57% (8/14) had fevers. Of the patients studied, 85% (12/14) had 2 or more of these signs present, and 36% (5/14) had all 3 present at the initial visit. Staphylococcus species were found in 13 of 14 cases with the last case growing a Streptococcus species [3]. The patient presented in this case study came to the ED with 2 of these findings.

Once SEA is suspected, MRI has been shown to be the imaging modality of choice. Once it is diagnosed, surgical intervention is often needed. This was the case with this patient. He was suspected of having and was subsequently diagnosed with SEA. Magnetic reso- nance imaging showed that the SEA and surgical intervention were required. The patient had Streptococcus grown on cultures. The purpose of this discussion, however, is not to determine the best method of diagnosing, treating an SEA, or what is the most common micro finding. Rather, it is to focus on clinical signs that should cause the clinician to include SEA on the differential diagnosis list.

Tyler J. Harris, MD? Jason P. Seamon, DO, MHS

1000 Monroe NW Dept of Emergency Medicine Grand Rapids, MI 49503, USA

?Corresponding author at: 100 Michigan St NE Grand Rapids, MI 49503, USA, mail code 49

E-mail addresses: [email protected] (T.J. Harris) [email protected] (J.P. Seamon)

http://dx.doi.org/10.1016/j.ajem.2014.05.029

References

1. Tang K, Xenos C, Sgouros S. Spontaneous spinal epidural abscess in a neonate. Childs Nerv Syst 2001;17:629-31.
2. Kiymaz Nejmi, Demir Ozgur. Spontaneous cervical paraspinal and epidural giant abscess in a child. Neurol Med Chir 2005;45:540-2.
3. Oktenoglu Tunc, Sasani Mehdi, Cetin Birsen, Bozkus Hakan, Ercelen Omur, Vural Metin, et al. Spontaneous pyogenic spinal epidural abcess. Turk Neurosurg 2011;21:74-82.