Large paraspinal abscess as a complication of infliximab therapy in Crohn's disease.

We report a 36-year-old man who developed a large epidural and paraspinal abscess as a complication of infliximab therapy being used for underlying Crohn's disease. Cultures of the collection grew methicillin-susceptible Staphylococcus aureus, and treatment consisted of abscess drainage, prolonged intravenous and oral flucloxacillin and temporary withholding of his infliximab. While infection-related complications are well described with infliximab therapy, this is the first description of a large paraspinal abscess with epidural extension.

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.

Invasive Pulmonary Aspergillosis in the Epidural Space in a Patient with Acute Myelogenous Leukemia with Myelodysplasia-related Changes: A Case Study and Literature Review of Vertebral Aspergillosis in Japan.

Vertebral aspergillosis is a rare infectious disease with a high mortality rate. We herein report a 70-year-old woman with acute myelogenous leukemia with myelodysplasia-related changes, nontuberculous mycobacteriosis, and bronchiectasis who presented with a fever and cough. Her clinical symptoms and laboratory test results suggested febrile neutropenia and pneumonia. However, her clinical course was further complicated by lower extremity weakness. Magnetic resonance imaging of the spine showed consolidation contiguously spreading toward the epidural space between the T4 and T5. Cytological testing of the pleural effusion revealed Aspergillus fumigatus. We also review and summarize previously reported cases of vertebral aspergillosis in Japan.

Microbiological Evaluation of the Extension Wire and Percutaneous Epidural Lead Anchor Site Following a "2-Stage Cut-Down" Spinal Cord Stimulator Procedure.

OBJECTIVES: There are concerns regarding bacterial colonization of the temporary extension leads and subsequent infection risk using the 2-stage cut-down approach in spinal cord stimulation (SCS). We sought to quantify the extent of bacterial colonization of the temporary extension wire and percutaneous epidural lead anchor site. MATERIALS AND METHODS: We conducted a cross-sectional observational study recruiting a pragmatic sample of 25 consecutive patients listed for a cut-down trial of SCS. We excluded patients undergoing revision procedures and those who had previously received a spinal cord stimulator. The primary outcome measure was the rate and type of colonization of the extension wires and lead anchor site. RESULTS: No surgical site infections were recorded in any of the patients and no late infections subsequent to insertion of the implantable pulse generator. Overall, 24% of patients grew organisms from the temporary extension wire. Five patients grew coagulase-negative Staphylococcus aureus, and 1 patient grew Enterococcus faecalis. There were no positive wound cultures from the anchor site of the epidural lead. CONCLUSIONS: Despite the high colonization rate of the temporary extension wire, there were no surgical site infections. We conclude that provided appropriate strategies for the management of surgical site infections are implemented, the 2-stage cut-down procedure is a safe approach that is not associated with a higher incidence of infection.

CT-Guided Biopsy in Suspected Spondylodiscitis--The Association of Paravertebral Inflammation with Microbial Pathogen Detection.

OBJECTIVES: To search for imaging characteristics distinguishing patients with successful from those with futile microbiological pathogen detection by CT-guided biopsy in suspected spondylodiscitis. METHODS: 34 consecutive patients with suspected spondylodiscitis underwent CT-guided biopsy for pathogen detection. MR-images were assessed for inflammatory infiltration of disks, adjacent vertebrae, epidural and paravertebral space. CT-images were reviewed for arrosion of adjacent end plates and reduced disk height. Biopsy samples were sent for microbiological examination in 34/34 patients, and for additional histological analysis in 28/34 patients. RESULTS: Paravertebral infiltration was present in all 10/10 patients with positive microbiology and occurred in only 12/24 patients with negative microbiology, resulting in a sensitivity of 100% and a specificity of 50% for pathogen detection. Despite its limited sensitivities, epidural infiltration and paravertebral abscesses showed considerably higher specificities of 83.3% and 90.9%, respectively. Paravertebral infiltration was more extensive in patients with positive as compared to negative microbiology (p = 0.002). Even though sensitivities for pathogen detection were also high in case of vertebral and disk infiltration, or end plate arrosion, specificities remained below 10%. CONCLUSIONS: Inflammatory infiltration of the paravertebral space indicated successful pathogen detection by CT-guided biopsy. Specificity was increased by the additional occurrence of epidural infiltration or paravertebral abscesses.

Compressive spinal epidural mass caused by Propionibacterium acnes.

BACKGROUND CONTEXT: Propionibacterium acnes is a gram-positive and facultative anaerobe bacillus that is found within sebaceous follicles of the human skin and recognized as a cause of infections after spinal surgery. To our knowledge, there has been no previously reported case of symptomatic compressive chronic inflammatory epidural mass caused by P. acnes in a patient with no prior spinal procedures. PURPOSE: This study aimed to describe a case of primary spinal infection by P. acnes. STUDY DESIGN: This study is a case report of a condition not previously described in the literature. METHODS: We present the history, physical examination, laboratory, radiographic, and histopathologic findings of a chronic inflammatory epidural mass caused by P. acnes in an immunocompetent adult male with no history of spinal surgery. RESULTS: A 51-year-old man presented to our clinic with sudden onset bilateral lower extremity weakness, inability to ambulate, and urinary retention. His past clinical history was remarkable only for hernia and left knee surgery but no spinal surgery. A year earlier, he had an infected draining abscess of the right axilla that was successfully managed medically. At presentation, his serum erythrocyte sedimentation rate and C-reactive protein were moderately elevated. Pan-spine magnetic resonance imaging was notable for a circumferential epidural mass from C5 to T6. He underwent emergent decompression; the mass was removed and sent for culture and pathologic evaluation. Cultures from all three specimens collected during surgery grew P. acnes, and the patient was successfully managed on intravenous ceftriaxone, while pathology revealed a chronic inflammatory reactive process. CONCLUSIONS: This is the first reported case of a primary spinal mass with chronic inflammatory features caused by P. acnes. In cases of epidural mass of unknown origin, both pathologic specimens and cultures should be obtained as slow-growing organisms may mimic oncologic processes.

Spinal epidural abscess and meningitis following short-term epidural catheterisation for postoperative analgaesia.

We present a case of a patient with a spinal epidural abscess (SEA) and meningitis following short-term epidural catheterisation for postoperative pain relief after a laparoscopic sigmoid resection. On the fifth postoperative day, 2 days after removal of the epidural catheter, the patient developed high fever, leucocytosis and elevated C reactive protein. Blood cultures showed a methicillin-sensitive Staphylococcus aureus infection. A photon emission tomography scan revealed increased activity of the spinal canal, suggesting S. aureus meningitis. A gadolinium-enhanced MRI showed a SEA that was localised at the epidural catheter insertion site. Conservative management with intravenous flucloxacillin was initiated, as no neurological deficits were seen. At last follow-up, 8 weeks postoperatively, the patient showed complete recovery.

Epidural abscess secondary to acute appendicitis.

A 62-year-old man presented via the emergency department with a 1-week history of back pain, on a background of non-insulin-dependent diabetes mellitus and rectal carcinoma for which he had undergone abdominoperineal resection, chemotherapy and radiotherapy. He exhibited signs of sepsis, midline lumbar spine tenderness and reduced hip flexion. CT of the abdomen and pelvis showed a presacral collection contiguous with the tip of the appendix, and MRI lumbar spine revealed abscess invation into the epidural space extending to T9. He underwent a laparotomy with washout of the presacral abscess and appendicectomy and prolonged course intravenous antibiotic therapy. At 3 months after initial presentation he had made a full clinical recovery with progressive radiological resolution of the epidural abscess. The objective of the case report is to highlight a unique and clinically significant complication of a very common pathology (appendicitis) and to briefly discuss other intra-abdominal sources of epidural abscess.

Isolation of Brucella melitensis biotype 3 from epidural empyema in a Bosnian immigrant in Germany.

Brucellosis is a regionally emerging infectious disease in Mediterranean countries with an increasing number of human cases and high morbidity rates. Here, we describe a case of severe B. melitensis biotype 3 infection in an immigrant who had contact with ruminants during a short-term stay in Bosnia before he returned to Germany. The patient developed thoracic spondylodiscitis accompanied by a large epidural empyema and neurological deficits. The isolated strain was characterized and compared to other strains from the Mediterranean region by multiple locus variable number of tandem repeat analysis, showing minor differences between emerging strains from neighbouring geographical areas.

Fusobacterium septicemia complicated by cerebral subdural and epidural empyemas: a rare case of Lemierre syndrome.

BACKGROUND: Lemierre syndrome is characterized by postanginal septicemia and internal jugular vein thrombophlebitis with secondary septic emboli, typically to the lungs. The central nervous system (CNS) is rarely involved. OBJECTIVE: To present a case of Lemierre syndrome featuring cerebral subdural and epidural empyemas. CASE REPORT: This case report describes the case of a 17-year-old youth with cerebral subdural and epidural empyemas. The findings of chest computed tomography of the neck and the blood cultures were compatible with Lemierre syndrome. The patient recovered well after antibiotic treatment and surgical debridement. CONCLUSION: Lemierre syndrome can result in infection spreading to the CNS, including cerebral subdural and epidural empyemas. This disease entity should be included in the differential diagnoses of CNS bacterial infections.

The clinical characteristics, therapeutic outcome, and prognostic factors of non-tuberculous bacterial spinal epidural abscess in adults: a hospital-based study.

PURPOSE: Nontuberculous bacterial spinal epidural abscess (SEA) is a serious infectious disease of spines. Despite proper management, SEA remains a disease of high morbidity. The epidemiological data in southern Taiwan is still lacking. METHODS: We analyzed the clinical features, laboratory data, magnetic resonance imaging findings, and therapeutic results of 45 bacterial SEA patients, collected during a study period of six years (2003- 2008). RESULTS: The 45 adult SEA patients, 32 were men and 13 women, aged 17-81 years (mean = 62 years). Thoracic and lumbosacral spines were the most commonly affected segments. Staphylococcus aureus was the most commonly implicated pathogen, accounting for infections in 67% (29/43) of the culture-proven cases, and 41% (12/29) of the S. aureus strains were oxacillin resistant. Gram-negative pathogens were implicated in 30% (13/43) of the culture-proven cases. Of the 45 patients, 19 underwent antibiotic treatment alone and 26 underwent medical and surgical treatments. The therapeutic results showed that 28 patients had a good prognosis and 17 had a poor prognosis. The significant prognostic factors included higher age, presence of diabetes mellitus and chronic heart disease, and initial presentation of altered consciousness. CONCLUSION: S. aureus was the most commonly implicated pathogen of adult SEA, and most S. aureus strains were oxacillin resistant. A relatively high incidence of Gram-negative infection was observed in this study. The epidemiological characteristics of the implicated pathogens must receive special consideration when selecting the empirical antibiotics. Despite adequate management, many adults with bacterial SEA had a high incidence of poor prognosis.

Clinical characteristics and therapeutic outcome of Gram-negative bacterial spinal epidural abscess in adults.

Gram-negative (G(-)) bacterial spinal epidural abscess (SEA) in adults is uncommon. Of the 42 adult patients with bacterial SEA admitted to the Chang Gung Memorial Hospital - Kaohsiung, between 2003 and 2007, 12 with G(-) SEA were included in this study. Of these 12 patients, seven were men and five were women; their ages ranged between 17 years and 81 years (median=72.5 years, mean=62.5 years). The patients were admitted at different stages of symptom onset (four were in the acute stage and four each in the subacute and chronic stages) and at different levels of neurologic deficit severity, ranging from back pain to paraplegia. Of these 12 patients, 11 had a medical and/or neurosurgical condition as the preceding event and four had a concomitant infection at other sites. Back pain (83%, 10/12) was the most common clinical presentation, followed by paraparesis (50%, 6/12), radiating pain (33%, 4/12), and urinary retention (25%, 3/12). The following causative G(-) pathogens were detected: Klebsiella pneumoniae (three patients), Salmonella spp. (three), Escherichia coli (two), Enterobacter spp. (two), Aeromonas hydrophila (one), and Prevotella melaninogenica (one). Both Enterobacter strains were resistant to multiple antibiotics. Of the 12 patients, eight (66.7%) had spontaneous SEA, whereas the remaining four had postneurosurgical SEA. Thoracic, lumbar, and thoracolumbar spine segments were the most commonly affected. After receiving medical and/or surgical treatment, 10 of the 12 patients (83%) survived, and all 10 recovered well. In conclusion, G(-) bacterial SEA accounted for 28.5% (12/42) of adult SEA. The causative G(-) pathogens found in this study were different from those reported in Western countries, and the strains noted in our study had multiple antibiotic resistance. Our findings suggest that the choice of initial empirical antibiotics for SEA should be carefully considered.

Spinal intradural granuloma as a complication of an infected cerebrospinal fluid drainage tube fragment--case report.

A 69-year-old man presented with subarachnoid hemorrhage due to a ruptured anterior communicating artery aneurysm. The aneurysm neck was clipped and a lumbar drainage tube was inserted for cerebrospinal fluid drainage. However, the tube was accidentally cut during removal and a fragment remained in the spinal canal. A subarachnoid, subcutaneous abscess appeared 7 days later, which was treated with antibiotics. He noted numbness of his left leg after 6 months, and gait disturbance manifested 3 months later. T(1)-weighted magnetic resonance (MR) imaging disclosed a well-enhanced extramedullary mass at the T9-10 intervertebral level, and T(2)-weighted MR imaging showed moderate edema around the peri-lesional spinal cord. The mass containing a drainage tube fragment was surgically removed. Histological examination confirmed granuloma due to chronic infection. This case suggests that retained tube fragments should be removed surgically, especially in the presence of infectious complications.

Extensive spinal epidural abscess as a complication of Crohn's disease.

A spinal epidural abscess is a neurosurgical emergency. Successful treatment frequently requires decompression of the spinal canal in combination with intravenous antibiotics. We report a patient with Crohn's disease who developed an extensive spinal epidural abscess communicating with an intra-abdominal collection.

Early detection of spinal sepsis.

Spinal sepsis (spinal epidural or subdural abscess) is a rare condition, which, if not diagnosed rapidly, can lead to paralysis or death. It is difficult to diagnose in its early stages as the symptoms are as yet non-specific. We aimed to identify predisposing factors and presenting symptoms that might aid in the early diagnosis of spinal sepsis. A case-control study was performed with non-pediatric patients who had been diagnosed with spinal sepsis from 1998 to 2007. Our control group comprised 80 randomly selected patients who had presented to the emergency department with back pain. We identified 72 patients with spinal sepsis. A multivariate analysis revealed that obesity (adjusted odds ratio [aOR] 21.4; 95% confidence interval [CI] 1.8-257.5) and alcoholism (aOR 6.5; 95% CI 1.3-32.8) were important predictive factors for spinal sepsis. To our knowledge, this is the first report that associates obesity and alcoholism with spinal sepsis.

Hematogenous Staphylococcus aureus discitis in adults can start outside the vertebral body.

BACKGROUND: Textbooks describe hematogenous discitis in adults as starting in the anterior vertebral body near the endplates. CASE REPORT: Hematogenous Staphylococcus aureus discitis developed at L1-L2 in an 81-year-old woman. On the first magnetic resonance imaging (MRI) scan performed 4 days after symptom onset, the only abnormalities were high signal from the disk on T2-weighted images, gadolinium enhancement of the soft tissues anterior to L1-L2, and epidural involvement. The endplates and vertebral bodies were normal. A subsequent MRI scan showed features typical of infectious discitis. DISCUSSION: We found a single similar case report in the medical literature, indicating that discitis starting outside the anterior vertebral body is rare. Nevertheless, an increasing number of similar cases may be diagnosed in the future, as MRI is being performed increasingly early in patients with a clinical suspicion of infectious discitis. CONCLUSION: Hematogenous infectious discitis in adults may start in some patients within the disk, soft tissues anterior to the disk, or epidural space. To avoid diagnostic and therapeutic delays, physicians should be aware of this unusual presentation of infectious discitis on very early MRI scans. When the clinical picture suggests discitis and findings from the early MRI scan are atypical, a repeat MRI scan should be obtained 1 week later to confirm the diagnosis.

Hematogenous spinal infection in central Greece.

STUDY DESIGN: We retrospectively analyzed spinal infection (SpI), in a teaching Hospital, in Central Greece. OBJECTIVE: To study presentation, etiology, and outcome of SpI in Central Greece. SUMMARY OF BACKGROUND DATA: SpI most frequently involves the intervertebral disc and adjacent vertebral bodies and can cause neurologic impairment. METHODS: Thirty three patients (23 men; age [mean +/- standard deviation], 60.6 +/- 11.3 years; disease duration, 44.5 [+/-54.7] days) hospitalized with SpI between January 2000 and December 2007 were included in the study. All patients had magnetic resonance imaging of the spine. RESULTS: Nineteen patients had pyogenic SpI (57.6%) and 14 patients had granulomatous SpI, 11 due to Brucella spp (34.4%), 3 due to Mycobacterium tuberculosis (9.4%). Staphylococcus aureus was the most frequent cause of pyogenic SpI, and spondylodiscitis (SpD) was the most frequent localization. Epidural entension was found in 8 of 17 pyogenic SpD and in 2 of 11 brucellar SpD patients. Subdural extension was detected in 3 patients with pyogenic SpD. Blood cultures were positive in 17 of 19 patients with pyogenic SpI. Two patients had concomitant endocarditis (staphylococcal 1, enterococcal 1). The most common associated disease was diabetes mellitus. All but 2 patients received medical treatment alone. Two patients died of uncontrollable sepsis. CONCLUSION: Back pain in presence of fever, constitutional symptoms, and/or high inflammation markers should alert physicians for spinal infection. In endemic areas, Brucella is a frequent cause of SpI.