Holocord spinal epidural abscess in a pregnant patient presenting as - PDF document

C ASE R EPORT N R APPORT DE CAS Holocord spinal epidural abscess in a pregnant patient presenting as premature labour: a rare presentation of an unusual diagnosis Kirsteen R. Burton, MSc, MBA, MD* 34 ; Xi Wang, MD 1 ; Deljit Dhanoa, BASc, MD, MBA, CCFP(EM), DABR I ABSTRACT traitement me ´dical et chirurgical. Il sera question de la fre ´quence, du tableau clinique, et des facteurs de risque de Spinal epidural abscess (SEA) is a rare clinical entity. It is less l’AER. Non traite ´e, l’affection produit des signes et symp- common when the entire epidural space is involved, known as to ˆ mes sensoriels ainsi que des troubles moteurs, qui a holocord or panspinal SEA, and it is even less common in a finissent par e ´ voluer vers la paralysie et la mort. Le pregnant patient. We report a case of methicillin-resistant traitement me ´dical et chirurgical de l’AER fera e ´galement Staphylococcus aureus holocord SEA in a 30-year-old female l’objet de discussion. Ce dernier peut se manifester par un at approximately 22 weeks’ gestational age who presented tableau insidieux et atypique malgre ´ l’e ´tendue de l’atteinte with lumbar pain and pelvic pressure and the urge to bear de l’espace e ´pidural. Aussi faudrait-il toujours envisager la down. Magnetic resonance imaging of the spine demon- possibilite ´ d’un AER chez les patients qui consultent au strated extensive SEA and meningitis from the foramen service des urgences pour des dorsalgies. magnum to the lumbar spine that was treated both medically and surgically. The incidence of, clinical presentation of, and risk factors for developing SEA are discussed. If untreated, Keywords: back pain, emergency, epidural abscess, magnetic expanding SEAs produce sensory symptoms and signs, resonance imaging, methicillin-resistant Staphylococcus motor dysfunction, and, eventually, paralysis and death. The aureus , osteomyelitis, pregnancy medical and surgical management of SEA is also discussed. SEA can have an insidious and atypical presentation despite Spinal epidural abscess (SEA) is an uncommon extensive involvement of the epidural space. Therefore, the disorder that is less common when it involves the diagnosis of SEA should always be considered in patients entire spinal canal in a pregnant patient. This case who present to the emergency department with back pain. describes a methicillin-resistant Staphylococcus aureus holocord SEA in a 30-year-old pregnant woman. We ´SUME ´ RE review the epidemiology of the condition and describe L’abce `s e ´pidural rachidien (AER) est une entite ´ clinique rare; the medical imaging findings, treatment options, and celui-ci l’est encore plus lorsque l’abce `s envahit tout l’espace prognosis. e ´pidural—on le qualifie alors de panrachidien—et il devient rarissime chez une femme enceinte. Ainsi sera expose ´, dans CASE REPORT le pre ´sent article, un cas d’abce `s e ´pidural panrachidien a ` Staphylococcus aureus re ´sistant a ` la me ´thicilline, chez une femme de 30 ans, enceinte d’environ 22 semaines, qui a A 30-year-old pregnant female, who was 21 weeks and consulte ´ pour des douleurs lombaires, une pression pelvi- 5 days of gestational age, presented to the emergency enne et l’envie impe ´ rieuse de pousser. L’imagerie par department (ED) complaining of lower back pain. The re ´sonance magne ´tique de la colonne verte ´brale a re ´ve ´le ´ la patient believed the pain was related to her kidneys pre ´sence d’un important AER et d’une me ´ningite s’e ´tendant because she had experienced similar pain previously, du trou occipital a ` la colonne lombaire, qui a ne ´cessite ´ un From the *Institute of Health, Policy, Management and Evaluation, 3 Medical Imaging, and 4 Biostatistics, University of Toronto, Toronto, ON; 1 Department of Diagnostic Radiology, McMaster University, Hamilton, ON; and I Medical Imaging, University of British Columbia, Fraser Health Authority, Vancouver, BC. Correspondence to: Dr. Deljit Dhanoa, Department of Radiology, Faculty of Medicine, University of British Columbia, 3350-950 W 10th Avenue, Vancouver BC V5Z 4E3; dhanoad@yahoo.com. This article has been peer reviewed. � Canadian Association of Emergency Physicians CJEM 2014;16(4):334-338 DOI 10.2310/8000.2013.131134 334 2014;16(4) CJEM N JCMU Downloaded from https://www.cambridge.org/core. IP address: 192.151.151.66, on 10 Aug 2020 at 02:03:21, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.2310/8000.2013.131134

Holocord spinal epidural abscess in a pregnant patient which was diagnosed as a genitourinary infection. The presentation, she reported back pain with movement emergency physician performed a urine dipstick and generalized weakness. On examination, she exhi- analysis, which was negative, and the fetal heart rate bited neck stiffness but normal sensory and motor was normal using fetal Doppler ultrasonography. The function in all limbs. Assessment for saddle anesthesia, patient was afebrile, and no antipyretics were adminis- rectal tone, and urinary retention was not documented. tered to the patient prior to ED presentation. The A lumbar puncture was performed due to the clinical patient did not complain of a fever, and there was no concern of meningitis, and frank pus was obtained. history of intravenous (IV) drug use on the initial visit. Given the findings on lumbar puncture, empirical A neurologic examination was not performed on the antibiotic therapy was initiated (cloxacillin and vanco- initial visit, and Obstetrics/Gynecology was not con- mycin), and gadolinium-enhanced magnetic resonance sulted. The patient was discharged with the diagnosis imaging (MRI) of the spine was performed (Figure 1 of muscular back pain and referred to her family and Figure 2). The MRI demonstrated marked physician for follow-up. enhancement of the spinal meninges from the foramen Four days later, the patient presented to a different magnum to the sacrum. A rim-enhancing epidural ED with acute pelvic pressure and the urge to bear collection measuring up to 1.8 cm in its widest down. The patient did not complain of a fever at the diameter extended from the upper to the lower lumbar second presentation. The pertinent negatives on the spine. The abnormal enhancement extended into the history by the emergency physician were absence of paraspinal muscles and into the right psoas muscle nausea, vomiting, vaginal bleeding, or a history sugges- consistent with extraspinal extension of infection, tive of ruptured membranes. The patient’s past social resulting in pyomyositis and intramuscular abscesses history was significant for cocaine use 1 week prior to (Figure 3). presentation, remote IV drug use, and a history of The patient was transferred to a neurosurgical prostitution. The patient’s previous medical history was tertiary care centre the same day, which was 5 days significant for asthma and iron deficiency anemia; she after the initial presentation, at which time, the was hepatitis C positive and human immunodeficiency patient’s neurologic status deteriorated significantly. virus (HIV) and hepatitis B negative. She became lethargic and was unable to ambulate due Vital signs were as follows: temperature 37.3 u C to a combination of pain with movement and weakness. (oral; 99.1 u F), blood pressure 116/72 mm Hg, respira- The only motion that she was able to perform actively tory rate 24 breaths/min, pulse 108 beats/min, and was extension and flexion of the great toe on one side. 100% oxygen saturation on room air. A physical Power in the lower legs was 1/5, and the only deep examination, including a screening neurologic exami- tendon reflex that could be elicited was a left Achilles nation that included gross sensory and motor skills of tendon reflex of 1 + . Subsequently, a partial T12 and all four extremities, was unremarkable. There were no L1/L2 laminectomy and epidural abscess evacuation 5 signs of saddle anesthesia or urinary retention, and days after initial presentation were performed. In the rectal tone was documented as normal. The patient was discharged home after normal obstetric ultrasono- graphy was performed. The discharge plan was to obtain serology including a complete blood count (CBC) and, in the interim, send the patient home with acetaminophen for pain control and follow-up with her obstetrician. Shortly postdischarge, the patient’s white blood cell count returned at 48.2 3 10 9 cells/L. The patient was contacted and requested to return to the ED for reassessment via ambulance later the same day. Her vital signs at that time were as follows: temperature Figure 1. Axial T 2 -weighted magnetic resonance imaging 37.5 u C (oral; 99.5 u F); blood pressure 94/54 mm Hg; study of the midthoracic spine showing a T 2 hyperintense respiratory rate 18 breaths/min; pulse 110 beats/min; collection of pus in the dorsal epidural space (*) causing and 100% oxygen saturation on room air. At this third mass effect on the thecal sac and displacing it ventrally. CJEM N JCMU 2014;16(4) 335 Downloaded from https://www.cambridge.org/core. IP address: 192.151.151.66, on 10 Aug 2020 at 02:03:21, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.2310/8000.2013.131134