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A case of nocardia epidural abscess
The Journal of Emergency Medicine, Vol. 16, No. 4, pp. 579 –581, 1998 Copyright © 1998 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/98 $19.00 1 .00
PII S0736-4679(98)00038-9
Clinical Communications
A CASE OF NOCARDIA EPIDURAL ABSCESS Allison L. Harvey,
MD,
Joseph Myslinski,
MD, FACEP,
and Lisa Ortiz,
MD
Department of Emergency Medicine, Richland Memorial Hospital, Columbia, South Carolina Reprint Address: Joseph Myslinski, MD, Residency Director, Richland Memorial Hospital, Department of Emergency Medicine, Columbia, SC 29203
e Abstract—Spinal epidural abscess due to nocardia is extremely rare. We report a patient who presented to our Emergency Department with a complaint of low back pain and fever, who was later found to have a spinal epidural abscess. Tissue cultures from the abscess grew nocardia asteroides. Magnetic resonance imaging scan is the imaging study of choice for diagnosing spinal epidural abscess. Treatment for nocardia spinal epidural abscess involves a combination of surgical debridement and prolonged sulfonamide administration. © 1998 Elsevier Science Inc.
prior to this visit, he also began experiencing intermittent episodes of urinary incontinence and numbness in the perianal region. Other complaints included a recent fever up to 38.9°C and vomiting. The patient’s past medical history was significant for the placement of a shunt for priapism one year prior and alcoholism. He denied any history of alcohol use in the past year, malignancy, HIV, or i.v. drug use. The patient’s physical examination was significant for tenderness over the lower lumbar spine, but there were no lesions or erythema noted. The right leg had decreased sensation to light touch and 4/5 strength when compared to the left leg. Additional neurologic findings included decreased rectal tone and decreased sensation to perianal pinprick. Initial vital signs were temperature 36.2°C, pulse 94 beats/min, respirations 22 breaths/min, blood pressure 107/68 torr; however, the temperature rose to 39.8°C over the next 5 h. Significant laboratory findings included a sodium of 134 mEq/L, a white blood cell count of 30,600/uL, and a platelet count of 801,000/uL. Urinalysis revealed 5 to 10 white blood cells/hpf and 11 bacteria. A chest x-ray study showed mild fibrotic changes within the left lingula and a possible coin lesion in the right upper lung field. Lumbar films were obtained and read by the radiologist as an old compression fracture at L4. Because of the patient’s neurologic symptoms, a lumbar computed tomography (CT) scan was obtained, which demonstrated a destructive lesion at L4. The patient was admitted with a presumptive diagno-
e Keywords—abscess; epidural; spinal; nocardia; emergency
INTRODUCTION The diagnosis of spinal epidural abscess is difficult to make and often missed until neurologic symptoms appear. Nocardiosis is an equally unusual diagnosis, with only 1000 cases reported in the United States each year (1). Nocardia, as a cause of spinal epidural abscess, has been reported in the English literature only five times since 1963 (2,3,4,5.6). We report a case of nocardia spinal epidural abscess in a patient who presented to our emergency department (ED).
Case Presentation A 39-year-old man presented to the emergency department with a 6-week history of low back pain. Two weeks
RECEIVED: 18 April 1997; FINAL ACCEPTED: 26 August 1997.
SUBMISSION RECEIVED:
12 August 1997; 579
580
A. L. Harvey, J. Myslinski, and L. Ortiz
sis of lung cancer with a metastatic L4 lesion and cauda equina syndrome (bladder incontinence, decreased rectal tone, and decreased rectal sensation). He was placed on dexamethasone and a metastatic workup was initiated. Because of the urinary symptoms, his fever was initially felt to be secondary to a urinary tract infection, and he was placed on ceftriaxone while awaiting the urine and blood culture results. His chest x-ray results were later attributed to rotation, which accentuated the right hilum. He subsequently underwent CT scans of the abdomen, pelvis, and head, which showed no evidence of primary or metastatic lesions. Magnetic Resonance Imaging (MRI) scan of the lumbar spine confirmed the destructive process at L4, but additionally revealed a soft tissue mass extending into the epidural space causing cord compression at L4. A CT guided needle biopsy at L4 demonstrated mucopurulent material. Gram’s stain of this fluid showed gram-positive rods with many polymorphonuclear leukocytes. The patient underwent emergent lumbar laminectomy and evacuation of the spinal epidural abscess. Review of the Gram’s stain revealed branching, beaded, gram-positive structures, and the diagnosis of nocardia was suggested. The diagnosis was confirmed when several cultures from the abscess grew nocardia asteroides. A triple antibiotic regimen consisting of i.v. trimethoprim/sulfamethoxazole, i.v. amikacin, and i.v. ceftriaxone was started. His post-operative course was unremarkable, and the neurological examination returned to normal within the week. The patient was followed as an outpatient by the infectious disease and neurosurgical specialists. He was continued on i.v. amikacin for 8 weeks, i.v. ceftriaxone for 6 months, and oral sulfisoxazole for 1 year. At the time his treatment was completed, he was ambulating without a brace and had minimal pain.
DISCUSSION Spinal epidural abscess is an unusual and frequently missed diagnosis. The incidence of spinal epidural abscess has been estimated at 0.83 per 10,000 admitted patients (7). A wide variety of admitting diagnoses have been reported in cases of spinal epidural abscess, with only 40% correctly identified initially (8). Upon review of the English literature there were only five cases of spinal epidural abscess due to nocardia identified (2– 6). The majority of patients diagnosed with spinal epidural abscess have some predisposing factor, such as an underlying illness, immunocompromised state, or i.v. drug use (7,8). Patients typically present with back pain and fever. Other commonly associated findings include an elevated white blood cell count (.10,000/uL), an
Figure 1. MRI scan of epidural abscess. A destructive process of the L4 vertebral body with associated spinal cord compression secondary to epidural abscess.
elevated erythrocyte sedimentation rate, and neurologic deficits. Many infected patients do not appear to have any risk factors (4,6,15). Routine x-ray studies of the spine will be normal early in the infectious process. When spinal epidural abscess is suspected, MRI scan is the imaging study of choice (Figure 1; Reference 9). MRI is preferred over computed tomography (CT) because of its ability to better evaluate a larger area of the spine with one image. Staphylococcus aureus remains the etiologic agent most commonly identified in patients with spinal epidural abscess. Although the incidence of S. aureus has ranged from 45– 62%, a wide variety of other etiologic agents are now being more frequently identified in spinal epidural abscesses. Nocardia, however, remains a rare etiologic agent (7,8,10 –12). Nocardia spp are gram-positive, rod shaped bacteria that are weakly acid fast and show true branching both in culture and in clinical lesions (13). They are strict aerobes found in the environment, particularly in the soil. Nocardia is a rare cause of infection in humans, but the recent medical literature reveals an increasing incidence (4,14). It is unknown whether this increase is due to the growing numbers of immunocompromised individuals or due to the increased frequency with which the diagnosis is suspected. Nocardia spp usually cause infection following inhalation or after direct inoculation (6,13). As a result, the most common infections result in pulmonary nocardiosis, or skin and subcutaneous (s.c.) tissue infections.
Nocardia
Dissemination to distant organs, in particular the central nervous system, is not rare. Nocardia should be suspected when the typical filamentous, gram-positive rods, often appearing “beaded” (with alternating gram-positive and gram-negative sections of the same filament) are seen on Gram’s stain. Acid fastness is especially helpful in the diagnosis, although unlike mycobacterium, nocardia spp are only weakly acid fast. Culture is not difficult if laboratory personnel are aware of the possibility of nocardiosis. Routine culture media and those used for fungus will usually show colonies within 48 –72 h. Superinfection with other organisms may obscure the diagnosis. Nocardia spp are very sensitive to sulfonamides, but clinical efficacy has been reported with numerous antimicrobials including ampicillin, imipenem, ceftriaxone, minocycline, aminoglycosides, and cycloserine (13). Most cases of spinal epidural abscess can be managed with decompressive laminectomy and debridement followed by 4 to 8 weeks of antimicrobial therapy. The management of nocardia spinal epidural abscess is also similar. A longer course of therapy with sulfonamides for at least 12 months has been recommended in cases of spinal epidural abscess due to nocardia (5). Acknowledgments—The authors would like to thank Dr. Bosko Postic for his invaluable knowledge and enthusiasm. Dr. Rosemary Lambert-Falls and Dr. William Rambo also assisted in the care of this patient.
581
REFERENCES 1. Hoeprich PD, Jordan MC, Ronald AR. Infectious diseases: A treatise of infectious processes. Philadelphia: J. B. Lippincott; 1994;488. 2. Epstein S, Holden M, Feldshuh J, et al. Unusual cause of spinal cord compression: nocardiosis. NY State J Med. 1963;63:3422–7. 3. Siao P, McCabe P, Yagnik P. Nocardial spinal epidural abscess. Neurology. 1989;39:996. 4. Yanoff DB, McGregor LC. Nocardial vertebral osteomyelitis. Clin Orthop. 1983;175:223– 6. 5. Awad I, Bay JW, Peterson JM. Nocardial osteomyelitis of the spine with epidural spinal cord compression—a case report. Neurosurgery. 1984;15:254 – 6. 6. Tokumoto N, Jacobs RA. Case report: nocardia osteomyelitis. Am J Med Sci. 1994;307:428 –33. 7. Hlavin ML, Kaminski HJ, Ross JS, et al. Spinal epidural abscess: a ten-year perspective. Neurosurgery. 1990;27:177– 84. 8. Darouiche RO, Hamill RJ, Greenberg SB, et al. Bacterial spinal epidural abscess review of 43 cases and literature survey. Medicine. 1992;71:369 – 85. 9. Rothman SL. The diagnosis of infections of the spine by modern imaging techniques. Orthop Clin North Am. 1996;27:15–31. 10. Curling OD, Gower DJ, McWhorter JM. Changing concepts in spinal epidural abscess: a report of 29 cases. Neurosurgery. 1990; 27:185–92. 11. Sapico FL. Microbiology and antimicrobial therapy of spinal infections. Orthop Clin North Am. 1996;27:9 –13. 12. King M. Spinal epidural abscess: an elusive diagnosis. South Med J. 1994;87:288 –9. 13. Ryan K. Actinomyces and nocardia. In: Sherris, JC, ed. Medical Microbiology: an introduction to infectious diseases. New York: Elsevier Science; 1990;463– 8. 14. Lyos AT, Tuchler RE, Malpica A, et al. Primary soft-tissue nocardiosis. Ann Plas Surg. 1995;34:212– 4. 15. Bross JE, Gordon G. Nocardial meningitis: case reports and review. Rev Infect Dis. 1991;13:160 –5.
PII S0736-4679(98)00038-9
Clinical Communications
A CASE OF NOCARDIA EPIDURAL ABSCESS Allison L. Harvey,
MD,
Joseph Myslinski,
MD, FACEP,
and Lisa Ortiz,
MD
Department of Emergency Medicine, Richland Memorial Hospital, Columbia, South Carolina Reprint Address: Joseph Myslinski, MD, Residency Director, Richland Memorial Hospital, Department of Emergency Medicine, Columbia, SC 29203
e Abstract—Spinal epidural abscess due to nocardia is extremely rare. We report a patient who presented to our Emergency Department with a complaint of low back pain and fever, who was later found to have a spinal epidural abscess. Tissue cultures from the abscess grew nocardia asteroides. Magnetic resonance imaging scan is the imaging study of choice for diagnosing spinal epidural abscess. Treatment for nocardia spinal epidural abscess involves a combination of surgical debridement and prolonged sulfonamide administration. © 1998 Elsevier Science Inc.
prior to this visit, he also began experiencing intermittent episodes of urinary incontinence and numbness in the perianal region. Other complaints included a recent fever up to 38.9°C and vomiting. The patient’s past medical history was significant for the placement of a shunt for priapism one year prior and alcoholism. He denied any history of alcohol use in the past year, malignancy, HIV, or i.v. drug use. The patient’s physical examination was significant for tenderness over the lower lumbar spine, but there were no lesions or erythema noted. The right leg had decreased sensation to light touch and 4/5 strength when compared to the left leg. Additional neurologic findings included decreased rectal tone and decreased sensation to perianal pinprick. Initial vital signs were temperature 36.2°C, pulse 94 beats/min, respirations 22 breaths/min, blood pressure 107/68 torr; however, the temperature rose to 39.8°C over the next 5 h. Significant laboratory findings included a sodium of 134 mEq/L, a white blood cell count of 30,600/uL, and a platelet count of 801,000/uL. Urinalysis revealed 5 to 10 white blood cells/hpf and 11 bacteria. A chest x-ray study showed mild fibrotic changes within the left lingula and a possible coin lesion in the right upper lung field. Lumbar films were obtained and read by the radiologist as an old compression fracture at L4. Because of the patient’s neurologic symptoms, a lumbar computed tomography (CT) scan was obtained, which demonstrated a destructive lesion at L4. The patient was admitted with a presumptive diagno-
e Keywords—abscess; epidural; spinal; nocardia; emergency
INTRODUCTION The diagnosis of spinal epidural abscess is difficult to make and often missed until neurologic symptoms appear. Nocardiosis is an equally unusual diagnosis, with only 1000 cases reported in the United States each year (1). Nocardia, as a cause of spinal epidural abscess, has been reported in the English literature only five times since 1963 (2,3,4,5.6). We report a case of nocardia spinal epidural abscess in a patient who presented to our emergency department (ED).
Case Presentation A 39-year-old man presented to the emergency department with a 6-week history of low back pain. Two weeks
RECEIVED: 18 April 1997; FINAL ACCEPTED: 26 August 1997.
SUBMISSION RECEIVED:
12 August 1997; 579
580
A. L. Harvey, J. Myslinski, and L. Ortiz
sis of lung cancer with a metastatic L4 lesion and cauda equina syndrome (bladder incontinence, decreased rectal tone, and decreased rectal sensation). He was placed on dexamethasone and a metastatic workup was initiated. Because of the urinary symptoms, his fever was initially felt to be secondary to a urinary tract infection, and he was placed on ceftriaxone while awaiting the urine and blood culture results. His chest x-ray results were later attributed to rotation, which accentuated the right hilum. He subsequently underwent CT scans of the abdomen, pelvis, and head, which showed no evidence of primary or metastatic lesions. Magnetic Resonance Imaging (MRI) scan of the lumbar spine confirmed the destructive process at L4, but additionally revealed a soft tissue mass extending into the epidural space causing cord compression at L4. A CT guided needle biopsy at L4 demonstrated mucopurulent material. Gram’s stain of this fluid showed gram-positive rods with many polymorphonuclear leukocytes. The patient underwent emergent lumbar laminectomy and evacuation of the spinal epidural abscess. Review of the Gram’s stain revealed branching, beaded, gram-positive structures, and the diagnosis of nocardia was suggested. The diagnosis was confirmed when several cultures from the abscess grew nocardia asteroides. A triple antibiotic regimen consisting of i.v. trimethoprim/sulfamethoxazole, i.v. amikacin, and i.v. ceftriaxone was started. His post-operative course was unremarkable, and the neurological examination returned to normal within the week. The patient was followed as an outpatient by the infectious disease and neurosurgical specialists. He was continued on i.v. amikacin for 8 weeks, i.v. ceftriaxone for 6 months, and oral sulfisoxazole for 1 year. At the time his treatment was completed, he was ambulating without a brace and had minimal pain.
DISCUSSION Spinal epidural abscess is an unusual and frequently missed diagnosis. The incidence of spinal epidural abscess has been estimated at 0.83 per 10,000 admitted patients (7). A wide variety of admitting diagnoses have been reported in cases of spinal epidural abscess, with only 40% correctly identified initially (8). Upon review of the English literature there were only five cases of spinal epidural abscess due to nocardia identified (2– 6). The majority of patients diagnosed with spinal epidural abscess have some predisposing factor, such as an underlying illness, immunocompromised state, or i.v. drug use (7,8). Patients typically present with back pain and fever. Other commonly associated findings include an elevated white blood cell count (.10,000/uL), an
Figure 1. MRI scan of epidural abscess. A destructive process of the L4 vertebral body with associated spinal cord compression secondary to epidural abscess.
elevated erythrocyte sedimentation rate, and neurologic deficits. Many infected patients do not appear to have any risk factors (4,6,15). Routine x-ray studies of the spine will be normal early in the infectious process. When spinal epidural abscess is suspected, MRI scan is the imaging study of choice (Figure 1; Reference 9). MRI is preferred over computed tomography (CT) because of its ability to better evaluate a larger area of the spine with one image. Staphylococcus aureus remains the etiologic agent most commonly identified in patients with spinal epidural abscess. Although the incidence of S. aureus has ranged from 45– 62%, a wide variety of other etiologic agents are now being more frequently identified in spinal epidural abscesses. Nocardia, however, remains a rare etiologic agent (7,8,10 –12). Nocardia spp are gram-positive, rod shaped bacteria that are weakly acid fast and show true branching both in culture and in clinical lesions (13). They are strict aerobes found in the environment, particularly in the soil. Nocardia is a rare cause of infection in humans, but the recent medical literature reveals an increasing incidence (4,14). It is unknown whether this increase is due to the growing numbers of immunocompromised individuals or due to the increased frequency with which the diagnosis is suspected. Nocardia spp usually cause infection following inhalation or after direct inoculation (6,13). As a result, the most common infections result in pulmonary nocardiosis, or skin and subcutaneous (s.c.) tissue infections.
Nocardia
Dissemination to distant organs, in particular the central nervous system, is not rare. Nocardia should be suspected when the typical filamentous, gram-positive rods, often appearing “beaded” (with alternating gram-positive and gram-negative sections of the same filament) are seen on Gram’s stain. Acid fastness is especially helpful in the diagnosis, although unlike mycobacterium, nocardia spp are only weakly acid fast. Culture is not difficult if laboratory personnel are aware of the possibility of nocardiosis. Routine culture media and those used for fungus will usually show colonies within 48 –72 h. Superinfection with other organisms may obscure the diagnosis. Nocardia spp are very sensitive to sulfonamides, but clinical efficacy has been reported with numerous antimicrobials including ampicillin, imipenem, ceftriaxone, minocycline, aminoglycosides, and cycloserine (13). Most cases of spinal epidural abscess can be managed with decompressive laminectomy and debridement followed by 4 to 8 weeks of antimicrobial therapy. The management of nocardia spinal epidural abscess is also similar. A longer course of therapy with sulfonamides for at least 12 months has been recommended in cases of spinal epidural abscess due to nocardia (5). Acknowledgments—The authors would like to thank Dr. Bosko Postic for his invaluable knowledge and enthusiasm. Dr. Rosemary Lambert-Falls and Dr. William Rambo also assisted in the care of this patient.
581
REFERENCES 1. Hoeprich PD, Jordan MC, Ronald AR. Infectious diseases: A treatise of infectious processes. Philadelphia: J. B. Lippincott; 1994;488. 2. Epstein S, Holden M, Feldshuh J, et al. Unusual cause of spinal cord compression: nocardiosis. NY State J Med. 1963;63:3422–7. 3. Siao P, McCabe P, Yagnik P. Nocardial spinal epidural abscess. Neurology. 1989;39:996. 4. Yanoff DB, McGregor LC. Nocardial vertebral osteomyelitis. Clin Orthop. 1983;175:223– 6. 5. Awad I, Bay JW, Peterson JM. Nocardial osteomyelitis of the spine with epidural spinal cord compression—a case report. Neurosurgery. 1984;15:254 – 6. 6. Tokumoto N, Jacobs RA. Case report: nocardia osteomyelitis. Am J Med Sci. 1994;307:428 –33. 7. Hlavin ML, Kaminski HJ, Ross JS, et al. Spinal epidural abscess: a ten-year perspective. Neurosurgery. 1990;27:177– 84. 8. Darouiche RO, Hamill RJ, Greenberg SB, et al. Bacterial spinal epidural abscess review of 43 cases and literature survey. Medicine. 1992;71:369 – 85. 9. Rothman SL. The diagnosis of infections of the spine by modern imaging techniques. Orthop Clin North Am. 1996;27:15–31. 10. Curling OD, Gower DJ, McWhorter JM. Changing concepts in spinal epidural abscess: a report of 29 cases. Neurosurgery. 1990; 27:185–92. 11. Sapico FL. Microbiology and antimicrobial therapy of spinal infections. Orthop Clin North Am. 1996;27:9 –13. 12. King M. Spinal epidural abscess: an elusive diagnosis. South Med J. 1994;87:288 –9. 13. Ryan K. Actinomyces and nocardia. In: Sherris, JC, ed. Medical Microbiology: an introduction to infectious diseases. New York: Elsevier Science; 1990;463– 8. 14. Lyos AT, Tuchler RE, Malpica A, et al. Primary soft-tissue nocardiosis. Ann Plas Surg. 1995;34:212– 4. 15. Bross JE, Gordon G. Nocardial meningitis: case reports and review. Rev Infect Dis. 1991;13:160 –5.