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 ~  Abstract
 ~ Introduction
 ~ Case Report
 ~ Discussion
 ~  References
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  Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 37  |  Issue : 4  |  Page : 590-592
 

A rare aetiology of spinal epidural abscess


1 Department of Clinical Microbiology and Immunology, Sir Gangaram Hospital, New Delhi, India
2 Department of Spinal Surgery, Sir Gangaram Hospital, New Delhi, India

Date of Submission28-Dec-2019
Date of Acceptance22-Feb-2020
Date of Web Publication18-May-2020

Correspondence Address:
Chand Wattal
Department of Clinical Microbiology and Immunology, Sir Gangaram Hospital, Raginder Nagar, New Delhi - 110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmm.IJMM_19_493

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 ~ Abstract 


Spinal epidural abscess (SEA) due to Streptococcus pneumoniae is a rare entity, but it is associated with high mortality. Here, we describe a rare case of pneumococcal SEA in an immunocompetent adult who presented with fever, lower back pain and paresis. Central nervous system examination revealed a decreased power in bilateral lower limbs. Magnetic resonance imaging of the lumbosacral spine showed loculated pus collection in the epidural space at the level of L4–L5 vertebrae. Pus obtained following L4–L5 decompression along with blood cultures grew S. pneumoniae. The patient was treated with clindamycin and cefoperazone-sulbactam for 6 weeks, and no relapse was noted on 11 months follow-up.


Keywords: India, spinal infections, Streptococcus pneumonia


How to cite this article:
Sheoran L, Goel N, Acharya S, Adsul N, Wattal C. A rare aetiology of spinal epidural abscess. Indian J Med Microbiol 2019;37:590-2

How to cite this URL:
Sheoran L, Goel N, Acharya S, Adsul N, Wattal C. A rare aetiology of spinal epidural abscess. Indian J Med Microbiol [serial online] 2019 [cited 2020 May 27];37:590-2. Available from: http://www.ijmm.org/text.asp?2019/37/4/590/284519





 ~ Introduction Top


Spinal infections (SIs) are relatively uncommon and represent 2%–7% of all musculoskeletal infections. It is an extremely destructive condition and a life-threatening infectious emergency that can lead to spinal instability, neurological damage including paraplegia.[1] Among the various SIs, spinal epidural abscess (SEA) is a relatively rare diagnosis with 5%–16% mortality rates worldwide, requiring a prompt medical and surgical intervention with <50% of surviving patients showing full recovery.[2] The incidence of SIs is on an incremental trend for the past 50 years which can be attributed to increase in ageing and immunosuppressed population, widespread use of vascular devices and other invasive instrumentations, rise in intravenous drug abuse along with the improved imaging techniques and diagnostics.[3]

Although Streptococcus pneumoniae is a common and virulent organism, its infection in the vertebral column is extremely rare (<3% of all SI).[4] To the best of our knowledge, only a few cases of SEA caused by S. pneumoniae have been reported till now. Here, we report the rare case of a pneumococcal SEA in an immunocompetent patient and probably the second from India.


 ~ Case Report Top


A 55-year-old morbidly obese male patient with no known co-morbidity, presented with the chief complaints of fever for 7 days, sudden onset pain in the lower back with progressive weakness of bilateral lower limbs for 5 days, bladder bowel incontinence for 5 days and inability to walk for 1 day. There was no history of trauma or any recent chest infection.

On physical examination, the patient was found to have high-grade fever (38.5°C), tachycardia, tachypnoea and normal oxygen saturation. The spinal examination showed no tenderness in the lower back. The central nervous system examination revealed the decreased (Grade 1/5) power in the bilateral lower limbs. The knee and ankle reflexes were not elicitable, and plantar reflex was mute. A complete cardiovascular, abdominal and respiratory examination was unremarkable, and no peripheral stigmata of endocarditis were noted.

Blood investigation revealed elevated total leucocyte count (19,007/dL), erythrocyte sedimentation rate (66 mm [1st h]) and C-reactive protein (182 mg/L). Magnetic resonance imaging (MRI) of the lumbosacral spine showed loculated areas of pus collection in the posterior epidural space and right paraspinal muscles along with arachnoiditis at the level of L4–L5 vertebrae [Figure 1].
Figure 1: Magnetic resonance imaging of the lumbosacral spine showing loculated areas of pus collection in posterior epidural space at the level of L4–L5 vertebrae

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A provisional diagnosis of pyogenic/fungal/tubercular epidural abscess with paraparesis was made, and right L4–L5 decompression was performed on the 2nd day of the admission. Blood cultures along with the pus specimen were sent for microbiological evaluation, and the patient was empirically started on injectable amikacin and cefoperazone-sulbactam.

Gram-stained smears of pus showed few polymorphonuclear cells and occasional Gram-positive diplococci. Other investigations such as KOH for fungal elements and TB-Xpert MTB/Rif for Mycobacterium tuberculosis complex from the pus specimen were non-contributory. Subsequently, on the next day, S. pneumoniae grew from both pus and blood culture (identified by MALDI-TOF/MS bioMérieux, Marcy-l-Etiole, France). The S. pneumoniae isolate was sensitive to penicillin, ceftriaxone, clindamycin, erythromycin, co-trimoxazole and levofloxacin (antibiotic susceptibility performed by VITEK® 2, bioMérieux, France). A final definitive diagnosis of pneumococcal pyogenic epidural abscess was made. On the basis of antibiotic susceptibility report, amikacin was stopped, and clindamycin was added to cefoperazone-sulbactam. Further, echocardiogram was also performed to look for any cardiac foci of infection but was found to be negative. During the hospital stay, the patient became afebrile and was discharged in a stable condition. On follow-up for 11 months, no relapse was noted.


 ~ Discussion Top


Although SEA is a relatively rare diagnosis (2.5–3.0/100,000), the incidence has increased to nearly double in the past 50 years.[2] Anatomically SEA is most commonly located in the lumbar spine (48%), followed by the thoracic (31%) and cervical spines (24%).[1] Male patients are affected more frequently than female patients in a ratio of 2:1 for unidentified reasons. Furthermore, a bimodal distribution with one peak below 20 years and the other between 50 and 70 years of age (overall average of 57.2 years).[5]

In a systematic review, Staphylococcus aureus was found to be the most common bacteria accounting for majority (63%) of SEA, followed by Gram-negative bacilli (8.1%), streptococcal infections (6.8%), coagulase-negative staphylococci (3%), polymicrobial (4.9%), anaerobes (2%) and unknown in almost 13.9% of SEA.[5] In a 10-year retrospective case–control study (from 1992 to 2002), Streptococcus species were found only in <3% (2/74) patients of SEA.[6] In the largest composite review from 1906 to 2014, only 26 pneumococcal SEA infections were documented.[7] The rare reports of pneumococcal SEA could be explained by the widespread implementation of paediatric pneumococcal conjugate vaccination and prior intake of antibiotics by many patients before laboratory investigations, which can result in the failure of the growth of this otherwise sensitive bacteria.[8],[9] In almost half of the SEA cases, microorganism reach spinal epidural space through haematogenous dissemination, making it the most common mode of spread. This is followed by contiguous spread and iatrogenic seeding (lumbar puncture and epidural analgesia) accounting for approximately 10%–30% and 15%, respectively. Among these pneumococcal SEA cases, about 46% (13/26) of patients had a history of respiratory symptoms, and only 8% (2/26) had endocarditis. Approximately 30%–40% of the SEA cases can occur without any recognised source of infection or predisposing condition, which could be suggestive of silent bacteraemia. The risk factors that have been observed for pneumococcal SEA are immunosuppression (32%), history of invasive spinal procedures (4%) and local or systemic foci of infection such as skin and soft-tissue infections or sepsis.[7]

Clinical diagnosis of SEA is difficult as initial clinical signs and symptoms are non-specific. In a study done by González-López et al., localised back pain was present in almost all cases followed by other symptoms such as motor weakness (52%), fever (44%), sensory abnormalities (40%) and bladder/bowel incontinence (27%). A 'classic triad' of fever, spine pain and neurologic deficits found in SEA patients is seen only in 13% and has not shown to be a reliable screening tool for diagnosing. The absence of a classical triad often delays the diagnosis and frequently leads to irreversible neurologic deficits.[10] Persistent back pain after a bacteraemic pneumococcal infection should prompt further evaluation. The absence of fever or leukocytosis cannot be used to exclude spinal or paraspinal pneumococcal infections.[7] On the contrary, inflammatory markers are seen to be elevated in all the cases of SEA and their normalisation correlates with the response to treatment. Initial empirical therapy for SEA should cover methicillin-resistant S. aureus, because of it being the most common cause of SEA and also it would be effective against drug-resistant pneumococci. Once a diagnosis of pneumococcal SI is made and antibiotic susceptibility results are available, the treatment should be given for the duration of 3–4 weeks. Sometimes, it is not possible to rule out vertebral osteomyelitis on MRI; therefore, antibiotic treatment should be extended to 6 weeks in such cases. Our patient received a complete 6-week course of parenteral antibiotics and had a favourable outcome which can be attributed to the prompt diagnosis.

In conclusion, though pneumococcal SEA is a rare entity and associated with high mortality, early diagnosis and treatment are essential for a favourable clinical outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ~ References Top

1.
Sobottke R, Röllinghoff M, Zarghooni K, Zarghooni K, Schlüter-Brust K, Delank KS, et al. Spondylodiscitis in the elderly patient: Clinical mid-term results and quality of life. Arch Orthop Trauma Surg 2010;130:1083-91.  Back to cited text no. 1
    
2.
Lener S, Hartmann S, Barbagallo GM, Certo F, Thomé C, Tschugg A. Management of spinal infection: A review of the literature. Acta Neurochir (Wien) 2018;160:487-96.  Back to cited text no. 2
    
3.
Corrah TW, Enoch DA, Aliyu SH, Lever AM. Bacteraemia and subsequent vertebral osteomyelitis: A retrospective review of 125 patients. QJM 2011;104:201-7.  Back to cited text no. 3
    
4.
Poyanli A, Poyanli O, Akan K, Sencer S. Pneumococcal vertebral osteomyelitis: A unique case with atypical clinical course. Spine (Phila Pa 1976) 2001;26:2397-9.  Back to cited text no. 4
    
5.
Arko L 4th, Quach E, Nguyen V, Chang D, Sukul V, Kim BS. Medical and surgical management of spinal epidural abscess: A systematic review. Neurosurg Focus 2014;37:E4.  Back to cited text no. 5
    
6.
Davis DP, Wold RM, Patel RJ, Tran AJ, Tokhi RN, Chan TC, et al. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med 2004;26:285-91.  Back to cited text no. 6
    
7.
Siddiq DM, Musher DM, Darouiche RO. Spinal and paraspinal pneumococcal infections-a review. Eur J Clin Microbiol Infect Dis 2014;33:517-27.  Back to cited text no. 7
    
8.
Griffin MR, Zhu Y, Moore MR, Whitney CG, Grijalva CG. U.S. hospitalizations for pneumonia after a decade of pneumococcal vaccination. N Engl J Med 2013;369:155-63.  Back to cited text no. 8
    
9.
Harris AM, Bramley AM, Jain S, Arnold SR, Ampofo K, Self WH, et al. Influence of antibiotics on the detection of bacteria by culture-based and culture-independent diagnostic tests in patients hospitalized with community-acquired pneumonia. Open Forum Infect Dis 2017;4:ofx014.  Back to cited text no. 9
    
10.
González-López JJ, Górgolas M, Muñiz J, López-Medrano F, Barnés PR, Fernández Guerrero ML. Spontaneous epidural abscess: Analysis of 15 cases with emphasis on diagnostic and prognostic factors. Eur J Intern Med 2009;20:514-7.  Back to cited text no. 10
    


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