Pyogenic psoas abscess on the dorsal side, and bacterial meningitis and spinal epidural abscess on the ventral side, both of which were induced by spontaneous discitis in a patient with diabetes mellitus: A case report.

Type 2 diabetes mellitus patients are immunocompromised, particularly under poorly controlled conditions, and thereby they could develop rare inflammatory diseases, such as spontaneous discitis, pyogenic psoas abscess, spinal epidural abscess and bacterial meningitis. Herein we report a pyogenic psoas abscess on the dorsal side, and bacterial meningitis and spinal epidural abscess on the ventral side, both of which were induced by spontaneous discitis in a patient with poorly controlled type 2 diabetes mellitus. This case was very rare and interesting, because we successfully treated various infections with antibiotics over a long period of time, complicated by hyperglycemic crises, although the patient suffered severe bone destruction and required rehabilitation for a long time.

Predictive factors for positive disco-vertebral biopsy culture in pyogenic vertebral osteomyelitis, and impact of fluoroscopic versus scanographic guidance.

BACKGROUND: The aims of this study were to identify the predictive factors for microbiological diagnosis through disco-vertebral biopsy (DVB) in patients with pyogenic vertebral osteomyelitis (PVO) and negative blood cultures, and compare the performance of DVB under fluoroscopic versus scanographic guidance. METHODS: We performed a cohort study comparing positive and negative DVB among patients with PVO. All cases of PVO undergoing a DVB for microbiological diagnosis in our center were retrospectively reviewed. Infections due to Mycobacterium tuberculosis, infections on foreign device, and non-septic diseases were excluded. Anamnestic, clinical, biological, microbiological, as well as radiological data were collected from medical charts thanks to a standardized data set. RESULTS: A total of 111 patients were screened; 88 patients were included. Microbiological cultures were positive in 53/88 (60.2%) patients. A thickening of the paravertebral tissue ≥10 mm on magnetic resonance imaging (MRI) in axial MR scans was a predictive factor of DVB microbiological positivity (52.4% vs. 13.3%; p = 0.006; OR = 5.4). Overall, 51 DVB were performed under fluoroscopic guidance and 37 under scanographic guidance. Considering lumbar DVB, 25/36 (69.4%) of cases yielded positive results under fluoroscopic guidance versus 5/15 (33.3%) under scanographic guidance (p = 0.02; OR = 4.4). No adverse event linked to DVB was notified. CONCLUSION: Every patient with PVO and negative blood cultures should undergo a DVB. A thickening of the paravertebral tissue ≥10 mm on MRI is associated with a higher rate of positive DVB culture. A lumbar DVB under fluoroscopic guidance is more sensitive than under scanographic guidance to identify the micro-organism involved.

Differentiation between Tuberculous and Pyogenic Spondylodiscitis: The Role of the Anterior Meningovertebral Ligament in Patients with Anterior Epidural Abscess.

BACKGROUND AND PURPOSE: Differentiation between tuberculous and pyogenic spondylodiscitis is a diagnostic challenge because imaging often does not reliably distinguish the 2 entities and percutaneous biopsies are often culture-negative. The purpose of this study was to determine whether violation of the anterior meningovertebral ligament in the setting of anterior epidural abscess discriminates between these entities. MATERIALS AND METHODS: This was a retrospective cohort study of all patients with acid-fast bacillus testing and anterior epidural abscess diagnosed on spinal MR imaging between May 2014 and September 2019, with a final diagnosis of tuberculous or pyogenic spondylodiscitis. Six cases of tuberculous spondylodiscitis (mean age, 45.5 years; 80% male) and 35 cases of pyogenic spondylodiscitis were evaluated (mean age, 56.6 years; 49% male). Demographic characteristics were recorded. Cases were assessed for anterior meningovertebral ligament destruction on MR imaging, as demonstrated by the shape of the epidural collection. Segmental location of the infection was also assessed. Independent 2-sample t tests and χ2 tests of independence were performed to evaluate the significance of the difference between the groups. RESULTS: Five of 6 (83.3%) cases of tuberculous epidural abscess had an intact anterior meningovertebral ligament, and 0/35 cases of pyogenic epidural abscess demonstrated an intact ligament (P < .001). The presence of an intact anterior meningovertebral ligament had 83.3% sensitivity and 100% specificity for tuberculous spondylodiscitis, a 100% positive predictive value, and a 97.2% negative predictive value. CONCLUSIONS: The presence of an intact anterior meningovertebral ligament has high sensitivity and specificity for tuberculous spondylodiscitis-associated epidural abscess, though these results should be validated in a larger sample.

Spinal holocord epidural abscess evacuated with double thoracic interval laminectomy: a rare case report with literature review.

Introduction: Holocord spinal cord epidural abscess is an uncommon condition that may result in serious neurological complications. Prompt diagnosis and early treatment is of paramount importance for an optimum clinical outcome. This case report describes a novel technique of interval laminectomy at two sites in the thoracic spine and surgical decompression with the help of infant feeding tubes in a case of holocord spinal epidural abscess (HSEA). Case presentation: An 18-year-old male presented to the emergency department with high-grade fever and low back ache of 2 weeks duration and loss of bowel and bladder control for 4 days. Neurological examination revealed intact motor power and sensation in all four limbs at presentation; however, there was a rapid deterioration to complete quadriplegia within 24 h. A diagnosis of holocord epidural abscess was made. Emergent decompression via interval thoracic laminectomy was done and appropriate antimicrobial therapy was instituted. At 10 months of follow-up, the individual showed complete neurological recovery. Discussion: The technique used in this case is unique with respect to the level of laminectomy and the manoeuvre employed for pus evacuation. Complete neurological and functional recovery was achieved despite complete paralysis pre-operatively. The outcome indicates that there may be good prognosis for individuals with HSEA accompanied with neurological deficit and emergent surgical decompression.

The effectiveness of a percutaneous endoscopic approach in a patient with psoas and epidural abscess accompanied by pyogenic spondylitis: a case report.

BACKGROUND: Psoas or epidural abscesses are often accompanied by pyogenic spondylitis and require drainage. Posterolateral percutaneous endoscopic techniques are usually used for hernia discectomy, but this approach is also useful in some cases of psoas or lumbar ventral epidural abscess. We here report a case of psoas and epidural abscesses accompanied by pyogenic spondylitis that was successfully treated by percutaneous endoscopic drainage. CASE PRESENTATION: Our patient was a 57-year-old Japanese woman who had been receiving chemotherapy for inflammatory breast cancer and who became unable to walk due to lower back and left leg pain. She was transported as an emergency to another hospital. Magnetic resonance imaging revealed psoas and epidural abscesses accompanied by pyogenic spondylitis, and methicillin-resistant Staphylococcus aureus was detected in a blood culture. Drainage of the psoas abscess was performed under echo guidance, but was not effective, and she was transferred to our institution. We performed percutaneous endoscopic drainage for the psoas and epidural abscesses. Immediate pain relief was achieved and the inflammatory reaction subsided after 8 weeks of antibiotic therapy with daptomycin. CONCLUSIONS: Percutaneous endoscopy allowed us to approach the psoas and epidural abscesses directly, enabling the immediate drainage of the abscesses with less burden on the patient.

Spinal Epidural Abscess in Children: Case Report and Review of the Literature.

BACKGROUND: Spinal epidural abscess (SEA) is a rare but serious infection in the epidural space along the spinal cord. SEA should be considered in patients with backache, fever, neurological deficits and/or spinal tenderness. Early diagnosis is imperative to prevent permanent neurological sequelae. CASE DESCRIPTION: We report a case of lumbar SEA in a 13-year-old girl who was immunocompetent and presented with spinal tenderness, back pain and 4 days of fever. A lumbar magnetic resonance imaging demonstrated an epidural abscess from L3-S1. She had emergent surgical intervention. Cultures grew methicillin-susceptible Staphylococcus aureus. She was also given long-term systemic antibiotics and she made a complete recovery within 2 months. CONCLUSIONS: SEA in an immunocompetent pediatric without risk factors is an extremely rare condition. In the English-language literature, there are only 30 reported cases in the past 19 years; our case brings the total to 31. Non-surgical treatment has been successful in both adult and pediatric patients under certain conditions. Still, there exists a risk of deterioration with non-surgical management, even in patients for whom treatment is begun in the absence of neurologic deficits. Tracking neurological deficits in children can be challenging, particularly in young children who are non-verbal and not yet ambulating, and a reliable neurologic examination is a critical component of non-surgical care. In consideration of these facts and the accelerated time frame of deterioration, once neurologic deficits are present, surgery plus systemic antibiotics remains the standard of care for pediatric SEA patients, with each individual case meriting review of the full clinical picture.

Fungal spinal epidural abscess: a case series of nine patients.

BACKGROUND CONTEXT: Fungal spinal epidural abscess (FSEA) is a rare entity with high morbidity and mortality. Reports describing the clinical features, diagnosis, treatment, and outcomes of FSEA are scarce in the literature. PURPOSE: This study aimed to describe the clinical features, diagnosis, treatment, and outcomes of FSEA. STUDY DESIGN: This study is designed as a retrospective clinical case series. PATIENT SAMPLE: A continuous series of patients with the diagnosis of FSEA who presented at our institution from 1993 to 2016. METHODS: We reviewed the electronic medical records of patients with SEA who were treated within our hospital system from 1993 to 2016. We only included SEA cases that were due to fungi. We also reviewed FSEA cases in the English language literature from 1952 to 2017 to analyze the features of FSEA. RESULTS: From a database of 1,053 SEA patients, we identified 9 patients with FSEA. Aspergillus fumigatus was isolated from 2 (22%) patients, and Candida species were isolated from 7 (78%). Focal spine pain, neurologic deficit, and fever were demonstrated in 89%, 50%, and 44% of FSEA cases, respectively. Five of nine cases involved the thoracic spine, and eight were located anterior to the thecal sac. Three cases had fungemia, six had long symptom duration (>2 weeks) prior to presentation, seven had concurrent immunosuppression, and eight had vertebral osteomyelitis. Additionally, one case had residual motor deficit at last follow-up, one had S1 sensory radicular symptoms, two suffered recurrent FSEA, two died within hospitalization, and two died within 90 days after discharge. CONCLUSIONS: In summary, the classic diagnostic triad (focal spine pain, neurologic deficit, and fever) is not of great clinical utility for FSEA. Biopsy, intraoperative tissue culture, and blood culture can be used to diagnose FSEA. The most common pathogens of FSEA are Aspergillus and Candida species. Therefore, empiric treatment for FSEA should cover these species while definitive identification is pending. FSEA is found in patients with poor baseline health status, which is the essential reason for its high mortality.

An unusual case of Nocardia cyriacigeorgica presenting with spinal abscesses in a renal transplant recipient and a review of the literature.

Nocardia species represent a well-recognized yet uncommon cause of opportunistic infections in humans. It most frequently presents as a pulmonary infection with or without central nervous system involvement. It is a very rare cause of spinal abscesses, with only 26 cases reported in the literature. Here we report a 49-year-old man with a history of renal transplantation who presented with low back pain and was diagnosed with epidural and paraspinal abscesses due to Nocardia cyriacigeorgica that was successfully treated with antimicrobial therapy alone. In addition to the case reported here, we also conducted a systematic review of the existing literature regarding spinal abscesses due to Nocardia species and examined the success of the various treatments utilized.

Independent predictors of spinal epidural abscess recurrence.

BACKGROUND CONTEXT: Recurrence of spinal epidural abscess (SEA) after treatment is an important cause of continued morbidity for patients. PURPOSE: The purpose of this study was to identify independent predictors of recurrence of SEA. STUDY DESIGN/SETTING: This was a retrospective, case-control study. PATIENT SAMPLE: Patients 18 years or older with a diagnosis of SEA admitted to our hospital system during the study period were included in the study sample. OUTCOME MEASURES: The outcome measure was recurrence of SEA, defined as a reaccumulation of pus or infected granulation tissue in the epidural space after initial treatment. METHODS: All patients older than 18 years admitted to our hospital system with a diagnosis of SEA from 1993 to 2016 were identified, and explanatory variables and outcomes were collected retrospectively. Patients 18 years or older diagnosed with SEA were included. We excluded patients whose treatment was initiated at an outside institution. Bivariate and multivariate analyses were performed to identify independent predictors of recurrence. RESULTS: We identified 1,053 patients with SEA. We only considered patients to be recurrence-free if they had no documented recurrence with greater than 20 weeks of follow-up. Five hundred thirty-four patients were recurrence-free and 38 had documented recurrence, yielding 572 patients who were included in this analysis. Bivariate and multivariate analyses identified three independent predictors of recurrence: history of intravenous drug use, fecal incontinence or retention, and local spinal wound infection. CONCLUSIONS: Patients with SEA who have a history of intravenous drug use, bowel dysfunction at presentation, or concurrent local spinal wound infection are at increased risk of disease recurrence. These patients ought to be closely followed up after discharge, with frequent serial imaging and aggressive antibiotic treatment.

Spinal epidural empyema extending from a pleural empyema: case description and anatomical overview.

We present a case of a patient with diabetes with a pleural empyema originated from a pyomyositis process established after a central line procedure. This empyema later on extended into the spinal canal deriving into an epidural empyema, leading towards a spinal neurogenic shock and death. We discuss the anatomical substrate for this extension as well as the anatomopathological findings observed in the autopsy.

Oesophageal pleural fistula presenting with Parvimonas micra infection causing cervical and brain abscesses.

Parvimonas micra (P. micra) infections causing spinal cord compression are extremely rare. We report an occult oesophageal pleural fistula presenting with spinal epidural and brain abscesses resulting in severe neurological deficits caused by P. micra. Molecular detection proved to be instrumental in identifying the causative pathogen. Essential management with decompression, drainage, antibiotics and fistula repair lead to a good outcome.

[Rare medico-surgical emergency: spinal epidural abscess (about 3 cases)]. / Une urgence médico-chirurgicale rare: l'abcès épidural rachidien (à propos de 03 cas).

The awareness about infections in the epidural space is increasing thanks to the development of neurosurgery, including MRI. Spinal epidural abscess is a rare pathology but extremely serious from a functional point of view and potentially life threatening. We report three cases of male patients (the first one aged 52 years, the second 57 years and the third 63 years) with diagnosed spinal epidural abscess. Two patients were admitted to the Neurosurgical Emergencies with slow progressive spinal cord compression evolving in the context of infection. The last patient complained of S1 sciatica pain in his right leg resistant to treatment associated with urinary incontinence. Entrance door of the infection wasn't identified during the initial assessment. All patients underwent spinal cord/radicular decompression surgery and evacuation of the epidural abscess via posterior approach. Bacteriological examination showed pyogenic germ justifying adequate prescription of antibiotic therapy in the three cases. The evolution was favorable in two cases. However one patient died three days after surgery due to severe sepsis.

Fever of unknown origin in a patient initially presenting with traveller's diarrhoea.

A 17-year-old male presented with diarrhoea and malaise following his return from Kenya and Tunisia. He was managed as a case of traveller's diarrhoea. Stool cultures were negative for pathogenic bacterial growth. Two weeks later he presented with worsening lower back pain. MRI of lumbosacral spine suggested L1 osteomyelitis. CT-guided spinal aspirate grew no organisms and repeat viral serology and blood cultures (including tuberculosis screening) were negative. He was treated with a 6-week course of ceftriaxone. Back pain did not improve and a repeat MRI scan 8 weeks after his antibiotic course indicated progressive changes in L1 extending to L2 with an intradiscal abscess. Repeat CT-guided spinal aspirate grew Salmonella arizonae sensitive to cotrimoxazole and ceftriaxone. He was treated with intravenous ceftriaxone and cotrimoxazole for 12 weeks. A 4-month follow-up MRI scan showed progressive improvement of the L1/L2 discitis with resolution of intradiscal fluid.

Spinal Subdural Abscess Following Laminectomy for Symptomatic Stenosis: A Report of 2 Cases and Review of the Literature.

BACKGROUND Spinal subdural abscesses, also known as empyemas, are rare infectious lesions, the exact incidence of which is unknown. Presentation is typically dramatic, with back pain, fever, motor, and sensory deficits. Rapid identification and surgical intervention with laminectomy, durotomy, and washout provides the best outcomes. While hematogenous spread of an extra-spinal infection is the most common cause of this condition, a significant number of cases result from iatrogenic mechanisms, including lumbar punctures, epidural injections, and surgery. CASE REPORT Here we present 2 cases: 1) an 87-year-old man with type 2 diabetes, schizophrenia, mild cognitive impairment, and symptomatic lumbar spinal stenosis and 2) a 62-year-old man with a prior L3-4 spinal fusion with symptomatic lumbar spinal stenosis. In both cases, patients underwent laminectomy for spinal stenosis and developed epidural abscess. Following successful drainage of the epidural abscess, they continued to be symptomatic, and repeat imaging revealed the presence of a subdural abscess that was subsequently evacuated. Case 1 had significant improvement with residual lower-extremity weakness, while Case 2 made a complete neurological recovery. CONCLUSIONS These cases illustrate patients at increased risk for developing this rare spinal infection, and demonstrate that rapid recognition and surgical treatment is key to cure and recovery. Review of the literature highlights pertinent risk factors and demonstrates nearly one-third of reported cases have an iatrogenic etiology. The cases presented here demonstrate that a subdural process should be suspected in any patient with intractable pain following treatment of an epidural abscess.

Tubercular Spinal Epidural Abscess of the Lumbosacral Region without Osseous Involvement: Comparison of Spinal MRI and Pathological Findings of the Resected Tissue.

We herein present a case of tubercular spinal epidural abscess (SEA) without osseous involvement that mimicked an acute bacterial abscess. This case manifested quite unusual findings not only radiographically, but also clinically compared with previously reported cases of tubercular SEA.

Cervical epidural extra-osseous Ewing sarcoma mimicking an epidural abscess.

We report a case of a 21-year-old woman presenting with quadriplegia which was initially diagnosed with an epidural abscess in view of her MR scan and raised inflammatory marker levels. Histology revealed an epidural extra-osseous Ewing's sarcoma (EES). Epidural location of EES is a very rare condition which can be very challenging to diagnose. Early diagnosis and surgical excision followed by chemotherapy represent the main stem of management.

Heterozygous congenital Factor VII deficiency with the 9729del4 mutation, associated with severe spontaneous intracranial bleeding in an adolescent male.

BACKGROUND: In congenital Factor (F) VII deficiency bleeding phenotype and intrinsic FVII activity levels don't always correlate. Patients with FVII activity levels <30% appear to have a higher bleeding propensity, but bleeding can also occur at higher FVII activity levels. Reasons for bleeding at higher FVII activity levels are unknown, and it remains challenging to manage such patients clinically. CASE: A 19year old male with spontaneous intracranial hemorrhage and FVII activity levels of 44%, requiring emergent surgical intervention and a strategy for FVII replacement. Genotyping showed the rare heterozygous FVII 9729del4 mutation. Bleed evacuation was complicated by epidural abscess requiring craniectomy, bone graft procedures, and prolonged administration of recombinant human (rh) activated FVII (FVIIa). The patient recovered without neurological deficits, and remains on prophylactic low dose treatment with rhFVIIa in relation to risky athletic activities. CONCLUSION: For clinicians, it is important to recognize that effects of rhFVIIa within these pathways are independent of its contribution to blood clot formation and cannot be assessed by clotting assays. Reduced FVII levels should therefore not be dismissed, as even a mild reduction may result in spontaneous bleeding. Treatment of mild FVII deficiency requires a careful case-by-case approach, based on the clinical scenario.