Absceso epidural espinal por Streptococcus agalactiae en un paciente inmunocompetente / Spinal epidural abscess caused by Streptococcus agalactiae in an immunocompetent patient

Introducción: Streptococcus agalactiae es un microorganismo causal infrecuente en el absceso epidural espinal (AEE) que generalmente afecta a pacientes con comorbilidades predisponentes y/o alguna potencial fuente de infección. Caso clínico: Presentamos el caso de un paciente de 53años, inmunocompetente y sin antecedentes médicos de interés, que desarrolló un cuadro de dolor lumbar, paraparesia y disfunción de esfínteres en el contexto de un síndrome febril sin foco conocido de una semana de evolución. La exploración neurológica mostró paraparesia flácida proximal, nivel sensitivo T10, esfínter anal atónico y reflejos osteotendinosos normales. La RM medular mostró un extenso AEE dorsal. Se realizó una laminectomía urgente con drenaje del absceso en menos de 24h y se inició antibioterapia empírica. El resultado del cultivo mostró Streptococcus agalactiae. Tras un estudio exhaustivo, no se encontró ninguna enfermedad predisponente ni fuente de la infección. Conclusiones: Describimos un caso infrecuente de AEE causado por Streptococcus agalactiae en un paciente sano sin factores predisponentes. Este caso subraya la importancia del diagnóstico precoz de esta entidad, dado que se puede asociar potencialmente con un mejor pronóstico

Background: Streptococcus agalactiae is an uncommon microorganism that causes spinal epidural abscess (SEA) and usually affects individuals with a predisposing condition or potential source of infection. Case description: We present the case of an immunocompetent 53-year-old patient with an unremarkable past medical history who developed progressive low extremity weakness, bowel and bladder dysfunction and genital sensory impairment. A neurological exam on admission revealed flaccid proximal paraparesis, T10 sensory level, atonic anal sphincter and normal myotatic reflexes. Urgent neuroimaging showed a large thoracic epidural spinal abscess. Laminectomy and abscess drainage were immediately performed and systemic antibiotic treatment was initiated. Abscess cultures revealed Streptococcus agalactiae. After an exhaustive workup no predisposing factors or local or systemic source for the infection were found. Conclusions: We report a singular case of spinal epidural abscess caused by Streptococcus agalactiae in a healthy patient with no predisposing factors. This case also highlights the importance of an early diagnosis and treatment to obtain a better neurological outcome

Spinal epidural abscess caused by Streptococcus agalactiae in an immunocompetent patient. / Absceso epidural espinal por Streptococcus agalactiae en un paciente inmunocompetente.

BACKGROUND: Streptococcus agalactiae is an uncommon microorganism that causes spinal epidural abscess (SEA) and usually affects individuals with a predisposing condition or potential source of infection. CASE DESCRIPTION: We present the case of an immunocompetent 53-year-old patient with an unremarkable past medical history who developed progressive low extremity weakness, bowel and bladder dysfunction and genital sensory impairment. A neurological exam on admission revealed flaccid proximal paraparesis, T10 sensory level, atonic anal sphincter and normal myotatic reflexes. Urgent neuroimaging showed a large thoracic epidural spinal abscess. Laminectomy and abscess drainage were immediately performed and systemic antibiotic treatment was initiated. Abscess cultures revealed Streptococcus agalactiae. After an exhaustive workup no predisposing factors or local or systemic source for the infection were found. CONCLUSIONS: We report a singular case of spinal epidural abscess caused by Streptococcus agalactiae in a healthy patient with no predisposing factors. This case also highlights the importance of an early diagnosis and treatment to obtain a better neurological outcome.

Misdiagnosis of posterior sequestered lumbar disc herniation: report of three cases and review of the literature.

INTRODUCTION: Posterior migration of sequestered disc is an extremely rare event that mimics more common spinal lesions as spinal tumors, making difficult its preoperative diagnosis and appropriate management. We retrospectively reviewed all lumbar disc herniations treated by surgery at our institution from 2006 to 2016 to identify cases with posterior sequestered disc fragments and possible misdiagnosis for other spinal lesions. Complementarily, a literature review of misdiagnosed cases of posterior migrated discs was undertaken. CASE REPORT: Three posterior sequestered lumbar disc cases (one intradural), were found among the 1153 reviewed surgeries. Two of them, presenting with progressive neurological deficit, were respectively misdiagnosed as pseudotumoral lesion and meningioma/neurogenic tumor on MRI. After intraoperative diagnosis and emergent resection, histology confirmed intervertebral disc tissue. The remaining case had an accurate preoperative diagnosis and after an initial conservative management finally underwent surgery because of refractory pain. Full recovery was achieved months after surgical treatment in all cases. DISCUSSION: Non-tumoral lesions are the most frequent misdiagnosis of posterior sequestered lumbar disc described in the literature. Early surgical treatment is the standard management due to high incidence of cauda equine syndrome (CES); however, spontaneous regression of posterior sequestered lumbar disc herniations has been recently reported. In conclusion low incidence and similar clinical and radiological features with other more common posterior spinal lesions like hematomas, synovial cyst or abscess turns posterior sequestered disc herniations a diagnosis challenge. Despite high incidence of CES, an initial conservative management should be evaluated in selected patients without neurological deficit and well-controlled pain.