RESUMO
BACKGROUND: An upper cervical spine epidural abscess (UCEA) is an epidural abscess that develops in the area between the occiput and the second cervical spine (axis). It is a rare diagnosis that carries the risk of instability of the atlantoaxial joint, and its management is not well-defined. It is known that the skin is the most common source of infection, and that diabetes mellitus (DM) is the most frequently reported risk factor. In this case, we present a patient diagnosed with UCEA, who achieved full neurological recovery postoperatively despite having neurological deficits for over five days prior to surgery. CASE PRESENTATION: We report the case of a 56-year-old male patient with no history of any prior medical conditions, who presented with headache, neck pain, and weakness of the left side. The weakness started approximately three days prior to his presentation. His initial work up revealed hyperglycemia and elevated HbA1c of 86 mmol/mol (10%). Magnetic resonance imaging (MRI) of the cervical spine revealed spondylitis of the C2 spine with an abscess at the craniocervical junction. He underwent a two-staged surgical approach: decompression and stabilisation. The patient achieved full motor recovery approximately three months postoperatively. CONCLUSIONS: We recommend screening for DM when a spinal epidural abscess (SEA) is diagnosed without readily identifiable risk factors. The optimal management in most SEA cases is surgical, which is particularly true for UCEA because of the risk of atlantoaxial joint instability. Full neurological recovery is possible even when the patient has been having deficits for more than five days.
Assuntos
Vértebras Cervicais , Abscesso Epidural , Humanos , Masculino , Abscesso Epidural/cirurgia , Abscesso Epidural/complicações , Abscesso Epidural/diagnóstico , Abscesso Epidural/diagnóstico por imagem , Pessoa de Meia-Idade , Vértebras Cervicais/cirurgia , Vértebras Cervicais/diagnóstico por imagem , Fatores de Risco , Complicações do Diabetes , Descompressão Cirúrgica/métodos , Imageamento por Ressonância MagnéticaAssuntos
Abscesso Epidural , Retalhos Cirúrgicos , Humanos , Retalhos Cirúrgicos/efeitos adversos , Abscesso Epidural/etiologia , Abscesso Epidural/diagnóstico , Abscesso Epidural/microbiologia , Cabelo/transplante , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/microbiologia , Feminino , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/etiologia , Masculino , Adulto , Procedimentos de Cirurgia Plástica/métodos , Procedimentos de Cirurgia Plástica/efeitos adversosRESUMO
BACKGROUND: Colorectal cancer is one of the most frequently diagnosed forms of cancer, and it is associated with several common symptoms and signs such as rectal bleeding, altered bowel habits, abdominal pain, anemia, and unintentional weight loss. Sciatica, a debilitating condition in which the patient experiences paresthesia and pain in the dermatome of associated lumbosacral nerve roots or sciatic nerve distribution, is not considered one of these. Here we present a case of colorectal cancer manifesting symptoms of sciatica alone. CASE PRESENTATION: A 68-year-old male presented with progressive lower back pain radiating to his left thigh and calf over L5/S1 dermatome. Sciatica was suspected and initially underwent conservative treatment with analgesics. However, the symptoms progressed and MRI revealed an epidural abscess surprisingly. Surgical debridement was performed and pus culture isolated Streptococcus gallolyticus. Based on the strong association of S. gallolyticus with colorectal cancer, the presence of this pathogen prompted further tumor evaluation, even in the absence of the typical symptoms and signs. This investigation ultimately leads to the diagnosis of sigmoid adenocarcinoma. CONCLUSIONS: Although rare, sciatica caused by S. gallolyticus infection of the spinal epidural space may serve as the initial presentation of colorectal cancer. Physicians should be aware of the strong association between S. gallolyticus and colorectal cancer. Based on what we currently know about the condition; a thorough systematic assessment of occult neoplasia for patients with S. gallolyticus infection is recommended.
Assuntos
Neoplasias do Colo , Abscesso Epidural , Ciática , Masculino , Humanos , Idoso , Ciática/diagnóstico , Ciática/etiologia , Abscesso Epidural/diagnóstico , Abscesso Epidural/cirurgia , Neoplasias do Colo/complicações , Neoplasias do Colo/diagnóstico , Dor Abdominal , ConscientizaçãoRESUMO
Infectious epiduritis and epidural abscesses are relatively rare pathologies but with important neurological consequences. A low incidence associated with an insidious clinical presentation leads to frequent delays in diagnosis, which worsen the prognosis of patients with the development of neurological deficits. While the evaluation of risk factors, a careful clinical examination and biological tests can guide to the diagnosis, the key examination remains magnetic resonance imaging (MRI) while lumbar puncture remains contraindicated. Although surgery (spinal decompression) has long been the treatment of choice, the current management of patients with infectious epiduritis is debated between surgery and conservative treatment with systemic antibiotic therapy.
Les épidurites infectieuses et les abcès épiduraux sont des pathologies relativement rares, mais avec des conséquences neurologiques redoutables. Une faible incidence et une présentation clinique souvent insidieuse engendrent de fréquents retards de diagnostic qui péjorent le pronostic des patients avec le développement de déficits neurologiques. Si l'évaluation des facteurs de risque, un examen clinique scrupuleux et des analyses biologiques peuvent guider vers le diagnostic, l'examen-clé reste l'imagerie par résonance magnétique (IRM). La ponction lombaire est contre-indiquée. Bien que l'approche chirurgicale ait longtemps été le traitement de choix, un traitement plus conservateur basé sur une antibiothérapie systémique est également discuté.
Assuntos
Abscesso Epidural , Cervicalgia , Humanos , Abscesso Epidural/complicações , Abscesso Epidural/diagnóstico , Abscesso Epidural/terapia , Imageamento por Ressonância Magnética , Laminectomia , Fatores de RiscoRESUMO
Spinal epidural abscess (SEA) is a rarest form of spinal infections and is characterized by the presence of pus in the space between the dura mater, and the osseoligamentous confines of the vertebral canal. This can cause spinal injury due to direct compression or local ischemia. The major etiology of SEA is bacterial and tuberculous in endemic regions. The incidence of fungal spinal abscess is relatively low and <5% of SEA is attributable to fungi. We, here, report a case of 77-year-old known patient of chronic renal disease on hemodialysis that presented with low-back pain for 15 days and was subsequently diagnosed with SEA by magnetic resonance imaging, and causative organism was identified as Candida by culture. The abscess was surgically drained after laminectomy. The patient improved with surgery and antifungal treatment.
Assuntos
Abscesso Epidural , Coluna Vertebral , Humanos , Idoso , Coluna Vertebral/diagnóstico por imagem , Abscesso Epidural/diagnóstico , Abscesso Epidural/microbiologia , Abscesso Epidural/cirurgia , Laminectomia , Imageamento por Ressonância MagnéticaRESUMO
OBJECTIVE: Vertebral osteomyelitis is a rare complication of coccidioidomycosis infection. Surgical intervention is indicated when there is failure of medical management or presence of neurological deficit, epidural abscess, or spinal instability. The relationship between timing of surgical intervention and recovery of neurological function has not been previously described. The purpose of this study was to investigate if the duration of neurological deficits at presentation affects neurological recovery after surgical intervention. METHODS: This was a retrospective study of all patients diagnosed with coccidioidomycosis involving the spine at a single tertiary care center between 2012 and 2021. Data collected included patient demographics, clinical presentation, radiographic information, and surgical intervention. The primary outcome was change in neurological examination after surgical intervention, quantified according to the American Spinal Injury Association Impairment Scale. The secondary outcome was the complication rate. Logistic regression was used to test if the duration of neurological deficits was associated with improvement in the neurological examination after surgery. RESULTS: Twenty-seven patients presented with spinal coccidioidomycosis between 2012 and 2021; 20 of these patients had vertebral involvement on spinal imaging with a median follow-up of 8.7 months (IQR 1.7-71.2 months). Of the 20 patients with vertebral involvement, 12 (60.0%) presented with a neurological deficit with a median duration of 20 days (range 1-61 days). Most patients presenting with neurological deficit (11/12, 91.7%) underwent surgical intervention. Nine (81.2%) of these 11 patients had an improved neurological examination after surgery and the other 2 had stable deficits. Seven patients had improved recovery sufficient to improve by 1 grade according to the AIS. The duration of neurological deficits on presentation was not significantly associated with neurological improvement after surgery (p = 0.49, Fisher's exact test). CONCLUSIONS: The duration of neurological deficits on presentation should not deter surgeons from operative intervention in cases of spinal coccidioidomycosis.
Assuntos
Coccidioidomicose , Abscesso Epidural , Doenças da Coluna Vertebral , Humanos , Coccidioidomicose/diagnóstico por imagem , Coccidioidomicose/cirurgia , Estudos Retrospectivos , Coluna Vertebral/cirurgia , Abscesso Epidural/diagnóstico , Abscesso Epidural/cirurgiaRESUMO
Spinal epidural abscess (SEA) is a very serious infection of the central nervous system (CNS). It is of very low incidence with a peak age in the geriatric age group. Immunocompromised patients are more susceptible to SEA. It can present with significant neurological deficits, which can be permanent if not identified and treated promptly. In this case report, a 75-year-old immunocompromised patient presented with progressive spastic quadriparesis and septicemia. He was diagnosed with a case of cervical spinal epidural abscess with underlying cord compression. Anterior retropharyngeal approach and button-hole disco-osteotomy of C5-C6 was performed and the cervical SEA was drained, followed by antibiotic saline irrigation (cranially and caudally) was done, total duration of surgery was 70 min. At the time of discharge (7th postoperative day), the patient improved neurologically and sepsis had resolved.
Assuntos
Abscesso Epidural , Masculino , Humanos , Idoso , Abscesso Epidural/complicações , Abscesso Epidural/cirurgia , Abscesso Epidural/diagnóstico , Coluna Vertebral/cirurgia , Antibacterianos/uso terapêutico , Osteotomia , DrenagemRESUMO
A 10-year-old boy presented with headache, fever, left-sided ptosis, and right-sided forehead soft tissue swelling. There was no recent history of trauma or infection. The patient had a large, fluctuant mass on the right side of his forehead, upgaze restriction, left-sided ptosis, and bilateral optic disk edema. Magnetic resonance imaging of the brain showed a frontal bone extradural fluid collection superficial to the superior sagittal sinus in keeping with an epidural abscess. There were multiple venous thromboses and thickening and enhancement of the dura, compatible with meningitis. There was right sphenoid sinusitis. This patient had Potts puffy tumor, a rare diagnosis associated with a forehead swelling from frontal bone osteomyelitis and subperiosteal abscess. It is seen in the pediatric population in association with sinusitis or trauma. Antibiotics, anticoagulation, and acetazolamide were initiated, and the epidural abscess was evacuated. The symptoms and signs resolved with treatment.
Assuntos
Abscesso Epidural , Tumor de Pott , Masculino , Humanos , Criança , Abscesso Epidural/diagnóstico , Abscesso Epidural/complicações , Tumor de Pott/complicações , Tumor de Pott/diagnósticoRESUMO
Spinal infection caused by Parvimonas micra (P. micra) is a rare infection. The characteristic imageology includes spondylodiscitis, spondylitis, paravertebral abscess, and epidural abscess. One case of spondylodiscitis of lumbar complicated with spinal epidural abscess caused by P. micra was admitted to the Department of Spinal Surgery, Xiangya Hospital, Central South University on February, 2023. This case is a 60 years old man with lower back pain and left lower limb numbness. MRI showed spondylitis, spondylodiscitis, and epidural abscess. The patient underwent debridement, decompression and fusion surgery. The culture of surgical sample was negative. P. micra was detected by metagenomic next-generation sequencing (mNGS). The postoperative antibiotic treatment included intravenous infusion of linezolid and piperacillin for 1 week, then intravenous infusion of ceftazidime and oral metronidazole for 2 weeks, followed by oral metronidazole and nerofloxacin for 2 weeks. During the follow-up, the lower back pain and left lower limb numbness was complete remission. Spinal infection caused by P. micra is extremely rare, when the culture is negative, mNGS can help the final diagnosis.
Assuntos
Discite , Abscesso Epidural , Firmicutes , Dor Lombar , Espondilite , Masculino , Humanos , Pessoa de Meia-Idade , Discite/tratamento farmacológico , Abscesso Epidural/diagnóstico , Abscesso Epidural/tratamento farmacológico , Abscesso Epidural/cirurgia , Dor Lombar/etiologia , Hipestesia , MetronidazolRESUMO
BACKGROUND Streptococcus oralis (S. oralis) is a gram-positive bacterium and component of the oral microbiota that can rarely cause opportunistic infection in the immunosuppressed. This report presents a 60-year-old man from Hong Kong with gingivitis and poorly controlled diabetes who visited his chiropractor with low back pain 2 weeks following mild COVID-19 and was diagnosed with paraspinal, psoas, and epidural abscess due to S. oralis. CASE REPORT The patient tested positive for COVID-19 when asymptomatic, then had a mild 10-day course of the illness, followed by low back pain 1 week later, prompting him to visit his primary care provider, who diagnosed sciatica and treated him with opioid analgesics. He presented to a chiropractor the following week, noting severe low back pain with radiation into the gluteal regions and posterior thighs, difficulty with ambulation, and mild neck pain. Considering the patient's diabetes, widespread symptoms, and weakness, the chiropractor ordered whole-spine magnetic resonance imaging, which suggested possible multifocal spinal abscess and referred him urgently to a spine surgeon. The surgeon conducted testing consistent with bacterial infection, and referred to an infectious disease specialist, who confirmed S. oralis spinal infection via lumbar paraspinal needle biopsy and culture. The patient was first treated with oral antibiotics, then intravenous antibiotics in a hospital. Over 4 weeks, his spinal pain improved, and laboratory markers of infection normalized. CONCLUSIONS This case illustrates an opportunistic pyogenic spinal infection including paraspinal, psoas, and epidural abscesses caused by S. oralis in an immunocompromised patient following COVID-19 illness.
Assuntos
COVID-19 , Diabetes Mellitus , Abscesso Epidural , Gengivite , Dor Lombar , Analgésicos Opioides , Antibacterianos/uso terapêutico , Dor nas Costas/etiologia , Diabetes Mellitus/tratamento farmacológico , Abscesso Epidural/diagnóstico , Abscesso Epidural/microbiologia , Gengivite/complicações , Gengivite/tratamento farmacológico , Humanos , Dor Lombar/etiologia , Masculino , Pessoa de Meia-Idade , Streptococcus oralisRESUMO
BACKGROUND: Recently, the incidence of pyogenic vertebral osteomyelitis with spinal epidural abscess (SEA) has increased. However, the most appropriate surgical management remains debatable, especially for older patients. This study aimed to compare the clinical course in older patients aged between 65 and 79 years and those 80 years or older undergoing surgery for SEA. METHODS: Data on patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality of patients diagnosed with pyogenic vertebral osteomyelitis and SEA between September 2005 and December 2021 were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index. RESULTS: We enrolled 45 patients aged 65-79 years and 32 patients ≥80 years. Patients ≥80 years had significantly higher rates of Charlson comorbidity index (9.2 ± 2.4) than younger patients (6.5 ± 2.5; P < 0.001). Arterial hypertension, renal failure, and dementia were significantly more prevalent in octogenarians (P < 0.05). Patients aged ≥80 years had a significantly longer length of hospitalization, while the intensive care unit stay was similar between groups. In-hospital mortality was significantly greater in those ≥80 years (n = 3, 9.4% vs. n = 0, 0.0%; P = 0.029), whereas no differences in 90-day mortality or 30-day readmission were observed. In the second-stage analysis, significant improvements in blood infection parameters and neurologic status were detected in both groups. Of adverse events, pneumonia occurred significantly more frequently in patients aged ≥80 years. CONCLUSIONS: Surgical management leads to significant improvements in both laboratory and clinical parameters in older patients. Nevertheless, a personalized medical approach is mandatory in frail patients, especially octogenarians. A clear discussion regarding the potential risk is unambiguously recommended.
Assuntos
Abscesso Epidural , Osteomielite , Idoso , Idoso de 80 Anos ou mais , Humanos , Abscesso Epidural/epidemiologia , Abscesso Epidural/cirurgia , Abscesso Epidural/diagnóstico , Seguimentos , Estudos Retrospectivos , Osteomielite/cirurgia , Progressão da Doença , Resultado do TratamentoRESUMO
BACKGROUND Pyogenic spondylitis comprises several clinical entities, including native vertebral osteomyelitis, septic discitis, pyogenic spondylodiscitis, and epidural abscess. The lumbar spine is most often infected, followed by the thoracic and cervical areas. It mainly develops (i) after spine surgery; (ii) from history of blunt trauma to the spinal column; (iii) from infections in adjacent structures (such as soft tissues); (iv) from iatrogenic inoculation after invasive procedures (such as lumbar puncture); and (v) from hematogenous bacterial spread to the vertebra (mainly through the venous route). Any delay in diagnosis and treatment can lead to significant spinal cord injury, permanent neurological damage, septicemia, and death. CASE REPORT We describe a 63-year-old man with no significant past medical history who presented with fever and an altered level of consciousness. Significant thoracic spine pain was also reported during the last 3 months. The final diagnosis was vertebral spondylodiscitis, contiguous spinal epidural abscess, and sepsis due to Bacteroides fragilis bacteremia. Clinical recovery was achieved after surgical decompressive therapy with abscess drainage combined with appropriate antibiotic therapy for 12 weeks. The primary focus of the infection was not clarified, despite all the investigations that were performed. CONCLUSIONS Spondylodiscitis, spinal epidural abscess, and sepsis as complications of Bacteroides fragilis bacteremia are rare in a patient without any previously known predisposing conditions and without an obvious primary focus. Early diagnosis and proper treatment of anaerobic spondylodiscitis, especially if epidural abscess and sepsis are present, are of great importance to reduce mortality and avoid long-term complications.
Assuntos
Bacteriemia , Discite , Abscesso Epidural , Sepse , Bacteriemia/complicações , Bacteriemia/diagnóstico , Bacteroides fragilis , Discite/diagnóstico , Discite/microbiologia , Abscesso Epidural/diagnóstico , Abscesso Epidural/terapia , Humanos , Vértebras Lombares/microbiologia , Masculino , Pessoa de Meia-Idade , Sepse/complicações , Sepse/diagnósticoRESUMO
Pyogenic spinal infections are uncommon, but their incidence has increased. Diagnosis is based on clinical, laboratory, and imaging findings. Delayed diagnosis occurs frequently and can lead to poor outcomes. Early radiographic findings are nonspecific; MRI is the best imaging study for diagnosis. The goal of treatment is to eradicate infection, prevent recurrence, preserve spinal stability, avoid deformity, relieve pain, and prevent or reverse neurologic deficit. Current guidelines recommend antibiotics be administered for 6 weeks if there is resolution of symptoms and normalization of inflammatory parameters. Surgery is required in patients with neurologic deficit, uncontrolled sepsis, spinal instability, deformity, and failure of medical treatment and to manage epidural abscess. Classic treatment of epidural abscess is surgical, but recent studies have challenged this approach. Surgical techniques used to manage these infections are varied; they include anterior, posterior, and combined approaches, and minimally invasive surgery. Current management has decreased mortality; however, the prognosis is affected by treatment failure, recurrent infection, or potential of persistent disability secondary to deformity, chronic pain, or permanent neurologic impairment.
Assuntos
Abscesso Epidural , Doenças da Coluna Vertebral , Abscesso Epidural/diagnóstico , Abscesso Epidural/cirurgia , Humanos , Imageamento por Ressonância Magnética , Estudos Retrospectivos , Doenças da Coluna Vertebral/diagnóstico , Doenças da Coluna Vertebral/cirurgia , Coluna VertebralRESUMO
INTRODUCTION: Spinal epidural abscess (SEA) is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of SEA, including presentation, initial evaluation, and management in the emergency department (ED) based on current evidence. DISCUSSION: SEA is a suppurative infection and infectious disease emergency that may result in significant morbidity and even mortality. It is a challenging diagnosis due to its range of risk factors and variety of presentations with up to 90% of patients misdiagnosed on their first ED visit. Factors associated with increased risk of SEA include immunocompromise, bacteremia, contiguous infection (e.g., psoas muscle abscess, osteomyelitis, skin infection), and spinal instrumentation. However, the absence of risk factors cannot be used to exclude SEA. The classic triad of back pain, fever, and neurologic deficit occurs in less than 8% of cases, though back pain is a common presenting symptom. Up to half of patients experience a neurologic abnormality, but fever is absent in 50%. Laboratory assessment may assist with inflammatory markers elevated in the majority of cases. Diagnosis includes magnetic resonance imaging with and without contrast and blood cultures, and management includes spinal specialist consultation and antibiotic therapy. CONCLUSIONS: An understanding of SEA can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
Assuntos
Abscesso Epidural , Dor nas Costas , Abscesso Epidural/diagnóstico , Abscesso Epidural/epidemiologia , Abscesso Epidural/terapia , Febre/etiologia , Humanos , Imageamento por Ressonância Magnética , Prevalência , Coluna VertebralRESUMO
Cauda equina syndrome is a potentially devastating spinal condition. The diagnosis of cauda equina syndrome lacks sensitivity and specificity, sometimes occurring after irreparable neurological damage has happened. Timely diagnosis and treatment is imperative for optimal outcomes and for avoiding medicolegal ramifications. Cauda equina syndrome results from conditions that compress the nerves in the lumbosacral spinal canal. Although no consensus definition exists, it generally presents with varying degrees of sensory loss, motor weakness, and bowel and bladder dysfunction (the latter of which is required to definitively establish the diagnosis). A thorough history and physical exam is imperative, followed by magnetic resonance or computed tomography imaging myelogram to aid in diagnosis and treatment. Once suspected, emergent spinal surgery referral is indicated, along with urgent decompression. Even with expeditious surgery, improvements remain inconsistent. However, early intervention has been shown to portend greater chance of neurologic recovery. All providers in clinical practice must understand the severity of this condition. Providers can optimize long-term patient outcomes and minimize the risk of litigation by open communication, good clinical practice, thorough documentation, and expeditious care.
Assuntos
Síndrome da Cauda Equina/diagnóstico , Síndrome da Cauda Equina/cirurgia , Descompressão Cirúrgica , Exame Neurológico , Síndrome da Cauda Equina/etiologia , Gerenciamento Clínico , Abscesso Epidural/complicações , Abscesso Epidural/diagnóstico , Abscesso Epidural/cirurgia , Hematoma Epidural Espinal/complicações , Hematoma Epidural Espinal/diagnóstico , Hematoma Epidural Espinal/cirurgia , Humanos , Deslocamento do Disco Intervertebral/complicações , Deslocamento do Disco Intervertebral/diagnóstico , Deslocamento do Disco Intervertebral/cirurgia , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Imageamento por Ressonância Magnética , Mielografia , Traumatismos da Coluna Vertebral/complicações , Traumatismos da Coluna Vertebral/diagnóstico , Traumatismos da Coluna Vertebral/cirurgia , Neoplasias da Coluna Vertebral/complicações , Neoplasias da Coluna Vertebral/diagnóstico , Neoplasias da Coluna Vertebral/cirurgia , Estenose Espinal/complicações , Estenose Espinal/diagnóstico , Estenose Espinal/cirurgia , Espondilolistese/complicações , Espondilolistese/diagnóstico , Espondilolistese/cirurgia , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND Mycobacterium avium intracellulare complex (MAI) is a member of the non-tuberculous mycobacteria family, which can cause both pulmonary and non-pulmonary disease. In patients with advanced HIV, it is known to cause disseminated disease. We present a case of a 65-year-old man who has sex with men (MSM) with AIDS, found to have spondylodiscitis and an epidural abscess, who had recently completed treatment for disseminated MAI. CASE REPORT The patient was a 65-year-old with AIDS secondary to HIV and a prior history of disseminated MAI, who presented with severe back pain. Upon presentation to the hospital, an MRI was performed, which was suggestive of spondylodiscitis and an epidural abscess. He was taken to surgery for a minimally invasive T12-L1 laminectomy and evacuation of the epidural abscess. Both traditional cultures and acid-fast bacillus (AFB) cultures were negative. Due to worsening pain, he was taken back to surgery for a repeat debridement and biopsy. Repeat cultures were positive for MAI. He was started on rifabutin, ethambutol, azithromycin, and moxifloxacin. Moxifloxacin was subsequently discontinued. He has had problems tolerating the treatment regimen, but is planned to complete an 18-24-month course. CONCLUSIONS For patients with AIDS who have a diagnosis of spondylodiscitis and an epidural abscess, an opportunistic infection such as MAI should be considered. A repeat biopsy should be considered if suspicion is still high, even despite initially negative cultures. Treatment regimens should be prolonged, despite difficulty with medication compliance.
Assuntos
Síndrome da Imunodeficiência Adquirida , Discite , Abscesso Epidural , Infecção por Mycobacterium avium-intracellulare , Minorias Sexuais e de Gênero , Idoso , Discite/diagnóstico , Abscesso Epidural/complicações , Abscesso Epidural/diagnóstico , Homossexualidade Masculina , Humanos , Masculino , Complexo Mycobacterium avium , Infecção por Mycobacterium avium-intracellulare/complicações , Infecção por Mycobacterium avium-intracellulare/diagnóstico , Recidiva Local de NeoplasiaRESUMO
INTRODUCTION: Spontaneous spinal epidural abscess (SEA) is a rare diagnosis; only eight cases have been reported during pregnancy. Diagnosis of SEA can be difficult, especially when the classic triad of fever, back pain, and neurologic deficits are not present. Early diagnosis and treatment are necessary to reduce potential morbidity and mortality. CASE PRESENTATIONS: We report two separate cases of SEA in pregnancy and summarize the existing literature. Case 1: A 20-year-old G1P0 presented at 35-week gestation with low back pain and lower extremity (LE) weakness. Magnetic resonance imaging (MRI) revealed thoracic SEA. The patient underwent cesarian delivery followed by posterior thoracic laminectomy and fusion (T9-11), abscess decompression, and antibiotic therapy. Unfortunately, there was a recurrence of her infection requiring a second irrigation and debridement 1 month after index procedure. At final follow-up, the patient had complete neurologic recovery. Case 2: A 38-year-old G10P0 presented at 36-week gestation in labor with LE weakness and difficulty ambulating. After delivery, she had significant LE neurologic deficits. MRI demonstrated thoracic osteodiscitis with associated epidural abscess. She underwent thoracic laminectomy and fusion (T7-12), abscess decompression, and antibiotic therapy. Unfortunately, despite aggressive treatment, she has persistent LE neurologic deficits. DISCUSSION: Pregnancy complicates the diagnosis and treatment strategies of SEA: back pain is very commonly underestimated, especially in the absence of fever and gross neurologic deficits. Prompt diagnosis and treatment are paramount to prevent neurologic decline and facilitate recovery. It is important to perform a focused physical exam noting motor strength, sensation, and reflexes. Coordinated management between the Emergency Department, OB-GYN, and spinal surgery team is required for best possible patient outcomes. Typically, management consists of aggressive surgical decompression and antibiotic therapy.
Assuntos
Abscesso Epidural , Adulto , Dor nas Costas , Descompressão Cirúrgica , Abscesso Epidural/diagnóstico , Abscesso Epidural/cirurgia , Feminino , Humanos , Laminectomia , Imageamento por Ressonância Magnética , Gravidez , Adulto JovemRESUMO
Sinogenic intracranial and orbital complications are infrequent complications of chronic rhinosinusitis with nasal polyposis (CRSwNP), leading to potentially fatal intracranial and orbital sequelae. The mortality and morbidity associated with these complications remain high despite the widespread use of antibiotics. We report a patient with CRSwNP presenting with acute onset extradural empyema and sixth nerve palsy in whom the diagnosis was delayed, necessitating early surgical intervention. Our case shows that delay in management and underdiagnosis of sinusitis with nasal polyposis can lead to devastating complications. A high index of suspicion, early recognition of the clinical findings and radiological evaluation with contrast-enhanced CT of paranasal sinuses, orbit and brain are essential to rule out fatal complications associated with CRSwNP. Timely endoscopic intervention and the use of antibiotics can lead to good outcomes, even in complicated cases.
Assuntos
Doenças do Nervo Abducente , Abscesso Epidural , Pólipos Nasais , Rinite , Sinusite , Doença Crônica , Abscesso Epidural/diagnóstico , Abscesso Epidural/diagnóstico por imagem , Humanos , Pólipos Nasais/diagnóstico , Pólipos Nasais/diagnóstico por imagem , Rinite/complicações , Rinite/diagnóstico , Sinusite/complicações , Sinusite/diagnóstico por imagemRESUMO
BACKGROUND: Anastomotic leakage following colorectal surgery remains a frequent complication. We report a rare case of a fatal epidural abscess caused by a colo-epidural fistula complicating a laparoscopic proctectomy. CASE PRESENTATION: A 62 year-old-man presented with weight loss, pelvic sepsis and neurological dysfunction four months after closing of the ileostomy following a laparoscopic proctectomy for a rectal adenocarcinoma one year ago. Cross-sectional imaging confirmed an epidural abscess caused by a chronic colorectal anastomotic leak. Systemic antibiotics and laparotomy with defunctioning pelvic loop colostomy were performed. Unfortunately, this management to control the major spinal infection failed. Epidural decompression and debridement was not possible due to his poor condition and the patient subsequently died. CONCLUSION: Colo-epidural fistula can occur as a consequence of colorectal anastomotic leakage. Prior to frank neurology symptoms and sepsis, patients may present with only a low-grade fever. Without prompt and aggressive management of colo-epidural infection, this severe complication can lead to paraplegia and death.
Assuntos
Cirurgia Colorretal , Procedimentos Cirúrgicos do Sistema Digestório , Abscesso Epidural , Meningite , Anastomose Cirúrgica , Fístula Anastomótica , Abscesso Epidural/diagnóstico , Abscesso Epidural/etiologia , Humanos , Pessoa de Meia-IdadeRESUMO
Las infecciones espinales son cuadros clínicos poco frecuentes, que exigen un alto índice de sospecha. La prevalencia de infecciones piógenas de la columna ha ido en aumento, en parte debido al envejecimiento de la población y a un mayor número de pacientes inmunocomprometidos. El estudio imagenológico se puede iniciar con radiografías simples, pero la resonancia magnética es el examen imagenológico de elección, ya que puede dar resultados positivos de forma precoz, entregando información más detallada del compromiso vertebral y tejidos blandos adyacentes. Aunque la clínica y los hallazgos imagenológicos nos pueden orientar, es importante intentar un diagnóstico microbiológico tomando cultivos y muestras para identificar al agente causal antes de iniciar los antibióticos; aunque es óptimo un tratamiento agente-específico, hasta un 25% de los casos queda sin diagnóstico del agente. El tratamiento es inicialmente médico, con antibióticos e inmovilización, pero se debe considerar la cirugía en casos de compromiso neurológico, deformidad progresiva, inestabilidad, sepsis no controlada o dolor intratable. El manejo quirúrgico actual consiste en el aseo y estabilización precoz de los segmentos vertebrales comprometidos. Descartar una endocarditis concomitante y el examen neurológico seriado son parte del manejo de estos pacientes.
Spinal infections are unusual conditions requiring a high index of suspicion for clinical diagnosis. There has been a global increase in the number of pyogenic spinal infections due to an aging population and a higher proportion of immunocompromised patients. The imaging study should start with plain radiographs, but magnetic resonance imaging (mri) is the gold standard for diagnosis. Mri can detect bone and disc changes earlier than other methods, and it provides detailed information on bone and adjacent soft tissues. Blood cultures and local samples for culture and pathology should be obtained, trying to identify the pathogen. According to the result, the most appropriate drug must be selected depending on susceptibility and penetration into spinal tissues. Treatment should start with antibiotics and immobilization; surgery should be considered in cases with neurological impairment, progressive deformity, spine instability, sepsis, or non-controlled pain. Current surgical treatment includes debridement and early stabilization. Practitioners should rule out endocarditis and perform a serial neurological examination managing these patients.