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.

Absceso epidural espinal: caso clínico pediátrico / Pediatric case report: Spinal epidural abscess

El absceso epidural espinal, una patología poco frecuente, presenta una incidencia de un caso cada 100 000 individuos, y se observa un aumento debido al incremento de factores de riesgo, tales como diabetes mellitus, anomalías espinales, tatuajes, acupuntura, analgesia epidural, sumado a una mayor disponibilidad de métodos de imágenes. Es una colección purulenta localizada entre la duramadre y el canal medular. Los gérmenes más comunes son Staphylococcus aureus y bacterias Gram-negativas. Sin tratamiento oportuno, evoluciona a la compresión medular y secuelas neurológicas permanentes. Una niña de 11 años se presentó con fiebre de 48 horas de evolución, dolor lumbar izquierdo, marcha antálgica con envaramiento lumbar. El examen neurológico era normal. Sobre los miembros inferiores, se observaban lesiones ampollares destechadas. La resonancia nuclear magnética mostró una imagen compatible con absceso epidural espinal. Evolucionó favorablemente. El tratamiento consistió en drenaje quirúrgico y antibióticos por 6 semanas. Del cultivo del material obtenido, creció Staphylococcus aureus meticilino sensible.

Spinal epidural abscess is an uncommon pathology. It has an incidence of one case per 100 000 individuals. An increase is observed due to the raise of risk factors such as diabetes mellitus, spinal abnormalities, tattoos, acupuncture, epidural analgesia, and a greater availability of imaging methods. It is a purulent collection located between the dura and the medullary canal. The most common germs are Staphylococcus aureus and Gram-negative bacteria. Without timely treatment, it evolves to medullary compression and permanent neurological sequelae. An 11-year-old girl was admitted with fever of 48 hs evolution, left lower back pain, antalgic gait with lumbar stiffness. Neurological examination was normal. Blunt blistering lesions were observed on lower limbs. Magnetic resonance imaging showed an image compatible with spinal epidural abscess. The evolutionwas favorable. Treatment consisted of surgical drainage and antibiotics for 6 weeks. From the culture of the material obtained, methidllin-sensitive Staphylococcus aureus was isolated.

[Pediatric case report: Spinal epidural abscess]. / Absceso epidural espinal: caso clínico pediátrico.

Spinal epidural abscess is an uncommon pathology. It has an incidence of one case per 100 000 individuals. An increase is observed due to the raise of risk factors such as diabetes mellitus, spinal abnormalities, tattoos, acupuncture, epidural analgesia, and a greater availability of imaging methods. It is a purulent collection located between the dura and the medullary canal. The most common germs are Staphylococcus aureus and Gram-negative bacteria. Without timely treatment, it evolves to medullary compression and permanent neurological sequelae. An 11-year-old girl was admitted with fever of 48 hs evolution, left lower back pain, antalgic gait with lumbar stiffness. Neurological examination was normal. Blunt blistering lesions were observed on lower limbs. Magnetic resonance imaging showed an image compatible with spinal epidural abscess. The evolutionwas favorable. Treatment consisted of surgical drainage and antibiotics for 6 weeks. From the culture of the material obtained, methidllin-sensitive Staphylococcus aureus was isolated.

El absceso epidural espinal, una patología poco frecuente, presenta una incidencia de un caso cada 100 000 individuos, y se observa un aumento debido al incremento de factores de riesgo, tales como diabetes mellitus, anomalías espinales, tatuajes, acupuntura, analgesia epidural, sumado a una mayor disponibilidad de métodos de imágenes. Es una colección purulenta localizada entre la duramadre y el canal medular. Los gérmenes más comunes son Staphylococcus aureus y bacterias Gram-negativas. Sin tratamiento oportuno, evoluciona a la compresión medular y secuelas neurológicas permanentes. Una niña de 11 años se presentó con fiebre de 48 horas de evolución, dolor lumbar izquierdo, marcha antálgica con envaramiento lumbar. El examen neurológico era normal. Sobre los miembros inferiores, se observaban lesiones ampollares destechadas. La resonancia nuclear magnética mostró una imagen compatible con absceso epidural espinal. Evolucionó favorablemente. El tratamiento consistió en drenaje quirúrgico y antibióticos por 6 semanas. Del cultivo del material obtenido, creció Staphylococcus aureus meticilino sensible.

Paracoccidioidomycosis in the spine: case report and review of the literature.

CONTEXT:: Paracoccidioidomycosis is a systemic form of mycosis that spreads hematogenously, secondarily to reactivation of lung infection or infection at another site or to new exposure to the causative agent. Few cases of bone involvement have been reported in the literature and involvement of the spine is extremely rare. CASE REPORT:: We describe a case of a 68-year-old male patient with spondylodiscitis at the levels L4-L5 caused by presence of the fungus Paracoccidioides brasiliensis, which was diagnosed through percutaneous biopsy. The patient was treated with sulfamethoxazole and trimethoprim for 36 months, with complete resolution of the symptoms. CONCLUSION:: Spondylodiscitis caused by the fungus Paracoccidioides brasiliensis is uncommon. However, in patients with chronic low-back pain who live or used to live in endemic regions, this infection should be considered as a possible differential diagnosis.

Paracoccidioidomycosis in the spine: case report and review of the literature / Paracoccidioidomicose na coluna vertebral: relato de caso e revisão da literatura

ABSTRACT: CONTEXT: Paracoccidioidomycosis is a systemic form of mycosis that spreads hematogenously, secondarily to reactivation of lung infection or infection at another site or to new exposure to the causative agent. Few cases of bone involvement have been reported in the literature and involvement of the spine is extremely rare. CASE REPORT: We describe a case of a 68-year-old male patient with spondylodiscitis at the levels L4-L5 caused by presence of the fungus Paracoccidioides brasiliensis, which was diagnosed through percutaneous biopsy. The patient was treated with sulfamethoxazole and trimethoprim for 36 months, with complete resolution of the symptoms. CONCLUSION: Spondylodiscitis caused by the fungus Paracoccidioides brasiliensis is uncommon. However, in patients with chronic low-back pain who live or used to live in endemic regions, this infection should be considered as a possible differential diagnosis.

RESUMO: CONTEXTO: Paracoccidioidomicose é uma micose sistêmica de disseminação hematogênica, secundária a reativação de uma infecção pulmonar ou de outro sítio, ou a uma nova exposição ao agente causador. Poucos casos de envolvimento ósseo são relatados na literatura, e o acometimento da coluna vertebral é extremamente raro. RELATO DE CASO: Descrevemos o caso de um paciente masculino de 68 anos, apresentando espondilodiscite no nível L4-L5, causada pela presença do fungo Paracoccidioides brasiliensis, diagnosticada após biópsia percutânea. O paciente foi tratado com sulfametoxazol e trimetoprim por 36 semanas, com resolução completa dos sintomas. CONCLUSÃO: A espondilodiscite causada pelo fungo Paracoccidioides brasiliensis é incomum, mas, em pacientes portadores de lombalgia crônica que viveram ou vivem em regiões endêmicas, deve ser considerada como um possível diagnóstico diferencial.

Espondilodiscitis con absceso intrarraquídeo y paraespinal causada por bacilo de Calmette-Guérin (BCG) / Spondilodyscitis with medullary and spinal abscess caused by Bacillus Calmette-Guérin (BCG)

Intravesical therapy with live-attenuated Mycobacterium bovis strain have demonstrated to be effective in the treatment of recurrent and high-grade superficial bladder tumors. The use of this therapy is widely extended; however spreading of bacillus from the injection site could be one rare complication that may cause infection in different locations. An appropriate anamnesis is very important to establish an etiological diagnostic of possible infections caused by M. bovis BCG. Laboratory diagnosis at species level is difficult because of the high genetic similarity (99.9%) with the other member of Mycobacterium tuberculosis complex. We present a case report who developed tuberculous spondylodiscitis by M. bovis BCG, which had a history of intravesical instillation for treatment of bladder cancer.

Las instilaciones intravesicales con la cepa viva atenuada de Mycobacterium bovis han demostrado su eficacia en el tratamiento de cáncer urotelial de vejiga. Su uso está ampliamente difundido; sin embargo, una reacción adversa infrecuente es la extravasación del bacilo del lugar de acción pudiendo causar infecciones en otras localizaciones. Una correcta anamnesis del paciente ayuda a orientar la etiología de posibles infecciones relacionadas con éste microorganismo. El diagnóstico de laboratorio a nivel de especie es dificultoso ya que comparte un 99,9% de identidad genética con los otros miembros del complejo Mycobacterium tuberculosis. Se presenta el caso de un paciente que desarrolló una espondilodiscitis tuberculosa por M. bovis BCG, el cual tenía antecedentes de instilaciones intravesicales para el tratamiento del cáncer de vejiga.

[Spondilodyscitis with medullary and spinal abscess caused by Bacillus Calmette-Guérin (BCG)]. / Espondilodiscitis con absceso intrarraquídeo y paraespinal causada por bacilo de Calmette-Guérin (BCG).

Intravesical therapy with live-attenuated Mycobacterium bovis strain have demonstrated to be effective in the treatment of recurrent and high-grade superficial bladder tumors. The use of this therapy is widely extended; however spreading of bacillus from the injection site could be one rare complication that may cause infection in different locations. An appropriate anamnesis is very important to establish an etiological diagnostic of possible infections caused by M. bovis BCG. Laboratory diagnosis at species level is difficult because of the high genetic similarity (99.9%) with the other member of Mycobacterium tuberculosis complex. We present a case report who developed tuberculous spondylodiscitis by M. bovis BCG, which had a history of intravesical instillation for treatment of bladder cancer.

Descending necrotizing mediastinitis associated with spinal cord abscess.

A 58-year-old man with a history of Ludwig's angina was admitted with a spinal cord abscess at the level of C2-T1 and associated osteomyelitic destruction of vertebral bodies, spinal cord compression, and secondary quadriparesis, followed by descending mediastinitis. A right posterolateral thoracotomy and a cervicotomy drained purulent exudates. A tracheostomy was performed, and the patient was discharged after 84 days.

Neurotuberculosis: an overview.

Although pulmonary tuberculosis is the most common form of this disease, neurotuberculosis is more severe and presents higher morbidity and mortality. Its diagnosis continues to challenge physicians all over the world. Contributing to this fact is the nonspecificity of its clinical manifestations, the low density of bacilli in the cerebrospinal fluid (CSF), and the delayed recovery of Mycobacterium tuberculosis through culture techniques. Thus, the diagnosis is largely based on suspicious symptoms, and the prognosis is directly related to the stage of the disease at the beginning of treatment. Even thought there is no consensus regarding the best therapeutic regimen, the WHO recommends using the same regimen used for pulmonary tuberculosis with a longer treatment time. It is important to note that in most cases, the doctor will not have a definite diagnosis at the beginning of the treatment. However, this should not delay the initiation of therapy. A delay in initiating treatment, in most cases, is directly associated with a poor prognosis. This review gives an overview of the current state of the neurotuberculosis research. It covers the epidemiological aspects of the infection, pathogenesis, principal clinical presentations, diagnosis highlighting neuroimaging, where a series of imaging are presented, prognosis, prevention and therapeutic regimens.

Poliradiculomielopatia causada por citomegalovirus en pacientes con SIDA / Cytomegalovirus polyradiculomyelopathy in AIDS

Se presenta una serie de 7 pacientes con SIDA en quienes se diagnosticó poliradiculomielopatía causada por Citomegalovirus (CMV-PRAM), con el objetivo de evaluar la eficacia del tratamiento con ganciclovir, foscarnet, o la combinación de ambos agentes. Se realizaron evaluaciones clínicas y neurológicas al momento de presentación y durante el tratamiento para el CMV. La fuerza muscular fue establecida de acuerdo a la escala del Medical Research Council (MRC). Se clasificó la respuesta al tratamiento de acuerdo al grado de mejoría en la fuerza muscular. En 6 de los 7 pacientes se observó una mejoría en la fuerza muscular con tratamiento anti-CMV alcanzando grado 4, o una mejoría de por lo menos 3 grados de acuerdo a la escala MRC. El paciente restante tuvo una respuesta intermedia. CMV-PRAM puede ser tratada con ganciclovir o la combinación de ganciclovir y foscarnet con buenos resultados.

Poliradiculomielopatia causada por citomegalovirus en pacientes con SIDA / Cytomegalovirus polyradiculomyelopathy in AIDS

Se presenta una serie de 7 pacientes con SIDA en quienes se diagnosticó poliradiculomielopatía causada por Citomegalovirus (CMV-PRAM), con el objetivo de evaluar la eficacia del tratamiento con ganciclovir, foscarnet, o la combinación de ambos agentes. Se realizaron evaluaciones clínicas y neurológicas al momento de presentación y durante el tratamiento para el CMV. La fuerza muscular fue establecida de acuerdo a la escala del Medical Research Council (MRC). Se clasificó la respuesta al tratamiento de acuerdo al grado de mejoría en la fuerza muscular. En 6 de los 7 pacientes se observó una mejoría en la fuerza muscular con tratamiento anti-CMV alcanzando grado 4, o una mejoría de por lo menos 3 grados de acuerdo a la escala MRC. El paciente restante tuvo una respuesta intermedia. CMV-PRAM puede ser tratada con ganciclovir o la combinación de ganciclovir y foscarnet con buenos resultados. (AU)

Intramedullary spinal cord paracoccidioidomycosis. Report of two cases.

Two cases of intramedullary paracoccidioidomycosis are reported. Paracoccidioidomycosis is a systemic disease that involves the buccopharyngeal mucosa, lungs lymph nodes and viscera and infrequently the central nervous system. Localization in the spinal cord is rare. Case 1: a 55-year old male admitted with crural pararesis, tactile/painful hypesthesia and sphincter disturbances of 15 days duration. Cutaneous-pulmonary blastomycosis was diagnosed 17 years ago. Myelotomography showed a blockade of T3-T4 (intramedullary lesion). The lesion surgically removed was a Paracoccidioides brasiliensis granuloma. Treatment with sulfadiazine was started after the surgery. Follow-up of 15 month showed an improvement of the clinical signs. Case 2: a 57-year old male was admitted elsewhere 6 months ago and, with a radiologic diagnosis of pulmonary paracoccidioidomycosis, was treated with amphotericin B. He progressively developer paresthesia and tactile/pain anaesthesia on the left side, sphincter disturbances and tetraparesis with bilateral extensor plantar response and clonus of the feet. Myelotomography showed a blockade of C4-C6 (intramedullary lesion). The lesion was not found during surgical exploration and the patient deteriorated and died. Post-mortem examination revealed an intramedullary tumor above the site of the mielotomy (Paracoccidioides brasiliensis granuloma). The preoperative diagnosis of intramedullary paracoccidioidomycotic granulomas is difficult because the clinical and radiologic manifestations are uncharacteristic. Clinical suspicion was possible in our cases based on the history of previous systemic disease. Contrary to intracranial localizations, paracoccidioidomycotic granulomas causing progressive spinal cord compression may require early surgery because response to clinical treatment is slow and the reversibility of neurological deficits depends on the promptness of the decompression.

Absceso espinal epidural: un caso clínico / Spinal epidural abscess: a clinical case

El absceso espinal epidural (AEE), representa para el médico una patología de dificil diagnóstico, tanto por su baja incidencia y por ende, bajo índice de sospecha, como por la reducida sensibilidad de los métodos imagenológicos de rutina: radiología simple de columna, cintigrafía ósea e incluso, tomografía axial computada. Se presenta un caso de AEE tratado en el servicio de medicina. De discuten los aspectos anatómicos, patogénicos, microbiológicos, diagnósticos y terapéuticos de la enfermedad, enfatizándo que en la precocidad del diagnóstico, se encuentra el mejor pronóstico de este cuadro