Intramedullary spinal abscess associated with intramedullary dermoid and infected dermal sinus:case report and review of the literature

Intramedullary spinal abscesses are extremely rare. Most occur secondary to cardiopulmonary spread;contiguous origin is less frequent. Few intramedullary spinal abscesses have been reported secondary to dermal sinus tracts. A dermoid sinus is a congenital lesion (closed simple dysraphism) with rare incidence.Dermoid sinuses can ease local invasion and spinal infections (meningitis, intradural extramedullary and intramedullary abscesses), usually with thoracolumbar involvement. Here we describe acase of a 20-month-old boy who presented with fever and refusal to walk 2 days prior to admission. On examination of the lumbar spine, a small sinus with skin stigmata was noted.Neurological evaluation revealed paraparesis more prominent on the left side, reduced tone and reflexes, left leg hypoesthesia,reduced anal tone, and urinary retention.MRI scan demonstrated intramedullary abscess extending from L2 to S1 level. The patient was urgently admitted for drainage of intramedullary abscess and excision of the dermal sinus tract. Proper antibiotic treatment was completed for 6 weeks with gradual improvement and ultimately full ambulation ability.

Spinal intramedullary abscess due to Candida albicans in an immunocompetent patient: A rare case report

Background: A spinal intramedullary abscess is a rare clinical entity in which patients classically present with a subacute myelopathy and progressive paraplegia, sensory deficits, and/or bowel and bladder dysfunction. We report the second case of spinal intramedullary abscess caused by Candida albicans to ever be published and the first case of its kind to be surgically managed. Case Description: A 44-year-old female presented with severe lumbar pain associated with paraparesis, incontinence, and paraplegia. She reported multiple hospital admissions and had a history of seizures, having already undergone treatment for neurotuberculosis and fungal infection of the central nervous system unsuccessfully. Nevertheless, no laboratory evidence of immunosuppression was identified on further investigation. Magnetic resonance imaging showed a D10-D11, well-circumscribed, intramedullary mass within the conus, which was hypointense on T1-weighted imaging and hyperintense on T2/STIR weighted. The patient underwent surgery for removal and biopsy of the lesion, which provided the diagnosis of an intramedullary abscess caused by C. albicans, a very rare condition with only one case reported in literature so far. Conclusion: C. albicans intramedullary abscess is a very rare clinical entity, especially in immunocompetent patients. We highlight C. albicans as an important etiology that must be considered in differential diagnosis. Critical evaluation of every case, early diagnosis, timely referral and surgical management of the abscess is essential to improve neurological outcome.

Pediatric Spinal Subdural Abscesses: A Report of Three Consecutive Patients

<b><i>Background:</i></b> Despite technological advances in medical treatment, the prognosis of the rarely reported spinal subdural abscesses (SSAs) has remained a serious entity largely unaffected, especially when they are diagnosed late. In this study, the authors aimed to present the surgical outcomes of 3 consecutive pediatric patients with SSA. <b><i>Materials and Methods:</i></b> We retrospectively reviewed the medical records of pediatric patients with spinal lesions who underwent surgery at 2 neurosurgical centers spanning 7 years, from 2012 to 2019. All pediatric patients who were diagnosed with SSA (<i>n</i> = 3) were selected as the core sample for this study. <b><i>Results:</i></b> Three pediatric patients (2 females and 1 male) with SSA were surgically treated. Holocord SSA was observed in 1 patient. The mean age was 7.1 ± 7.7 years. The most common presenting symptoms were gait disturbance and weakness of lower extremities (100%). The mean preoperative course was 5.7 ± 4.0 weeks. The causative pathogens were <i>Escherichia coli</i> (<i>E. coli)</i> and <i>M. tuberculosis</i>. In the 2nd case, the pathogen was non-tuberculosis mycobacterium in the extramedullary abscess. In the 44th postoperative month, she underwent surgery for intramedullary abscess. The causative pathogen was <i>E. coli</i>. Except for 1 male adolescent who presented with severe clinical status (paraplegic), the improvement was observed in all patients at their last follow-up after 50.3 ± 43.5 months of average. <b><i>Conclusions:</i></b> Drainage followed by appropriate antibiotics is the optimal treatment for SSAs. Early diagnosis and urgent surgical treatment are essential for a good prognosis. All surgically treated SSA patients with neurological deficits were rehabilitated with physical therapy postoperatively.

Cryptogenic cervical intramedullary abscess with rapidly progressive myelopathy: illustrative case

BACKGROUNDThe purpose of the present case report is to highlight the presentation, workup, clinical decision making, and operative intervention for a 68-year-old woman who developed rapidly progressive myelopathy secondary to idiopathic cervical intramedullary abscess.OBSERVATIONSThe patient underwent laminectomy and aspiration/biopsy of the lesion. Intraoperatively, division of the posterior median sulcus released a large volume of purulent material growing the oral pathogens Eikenella corrodens and Gemella morbillorum. Broad-spectrum antibiotics were initiated postoperatively. At the 6-month follow-up, the patient had almost completely recovered with some persistent hand dysesthesia. Complete infectious workup, including full dental assessment and an echocardiogram, failed to reveal the source of her infection.LESSONSThe authors report the first case of cryptogenic spinal intramedullary abscess secondary to Eikenella spp. and Gemella spp. coinfection. Intramedullary abscesses are exceptionally rare and most commonly develop in children with dermal sinus malformations or in the context of immunosuppression. In adults without risk factors, they can readily be mistaken for more common pathologies in this age group, such as intramedullary neoplasms or demyelinating disease. Prompt diagnosis and management based on rapidly progressive myelopathy, assessment of infectious risk factors and/or symptoms, and targeted imaging are critical to avoid potentially devastating neurological sequelae.

Intramedullary abscess associated with acute bacterial meningitis: a case report and review of the literature

Intramedullary spinal cord abscess (ISCA) is a rare infection of the central nervous system. Untreated, it may result in significant morbidity and mortality. We describe the case of a 34-year-old man, who initially was admitted for bacterial meningitis. 3 days after initiation of antibiotic therapy, a gradually and progressive weakness appeared on the left side of his body with numbness on the contralateral side. MRI of the spine demonstrated an ISCA at level of C4. A myelotomy and surgical drainage was performed. Postoperatively, the patient had improved significantly his neurological deficit. ISCA is still a life-threatening condition, we point out that the diagnosis should be highly suspected, if a cystic spinal cord lesion is surrounded by significant medullar edema associated with fast onset of symptoms, especially in a context of sepsis or acuate meningitis. Prompt surgical evacuation followed by adequate antibiotic therapy, are the mainstays of treatment.

1412. Spontaneous Intramedullary Abscess from Streptococcus anginosus Group: A Case Report and a Review of the Literature

Background Intramedullary abscess of the spinal cord (IASC) symptoms are often nonspecific with the diagnosis rarely considered on the initial differential. This can delay surgical management and may lead to permanent neurological deficits or mortality. Additionally, many organisms are implicated in IASC, leading to uncertainty in empiric antimicrobial therapy. Methods This case report follows a patient with IASC due to Streptococcus anginosus group (SAG). We also review a 25-case meta-analysis of IASC and 5 cases of SAG IASC. Results A 65-year-old woman with an unremarkable past medical history presented with 2 weeks of neck pain and paresthesias. She was afebrile with no systemic signs of infection or abnormal laboratory markers. MRI revealed an 8mm lesion at C4-C5 with edema C1-T1 and she received high-dose steroids for suspected malignancy. Follow-up MRI 4 days later revealed rapid progression of the lesion to 14mm, consistent with an infectious process (Figure 1). The patient received empiric therapy with ceftriaxone, vancomycin, and metronidazole. She underwent a C2-C7 laminectomy with midline myelotomy for evacuation of the abscess. Due to clinical and radiographic progression she required a second surgical wash-out 4 days later. Her intraoperative cultures grew SAG and her regimen was changed to penicillin and vancomycin. Her course was complicated by eosinophilia requiring meropenem and later linezolid to complete a 6-week course, during which she improved clinically and neurologically. Our review demonstrated that 40% of cases presented with fever. The majority of cases were idiopathic with the organisms known in 70% of cases. Surgery and IV antibiotics were used in 83% of cases and one case required a second surgery. A wide range of antibiotic regimens were reported with no consensus on how to best preserve neurological function. Conclusion This case highlights the complexities in diagnosing and managing IASC. We suspect that due to the protected nature of the intramedullary space, the infection may not trigger constitutional symptoms or a systemic inflammatory response. In patients who present with significant neurological deficits, MRI may reveal IASC and this should prompt immediate initiation of antibiotics that penetrate the blood–brain barrier and surgical intervention. Disclosures All authors: No reported disclosures.