- Email: [email protected]
Spinal Epidural Abscess Masquerading as an Acute Abdomen
Pediatric Neurology 50 (2014) 540e541
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Visual Diagnosis
Spinal Epidural Abscess Masquerading as an Acute Abdomen Manish Prasad MRCPCH *, Natasha De Vere MRCPCH Department of Paediatrics, Pinderfield General Hospital, Wakefield, UK
Case Summary A previously well 14-year-old girl presented with a 2-day history of fever and worsening abdominal and generalized back pain. She was acutely unwell, requiring fluid resuscitation. Her systemic examination revealed abdominal tenderness with guarding and bilateral renal angle tenderness. Examination of the spine was normal with no bony tenderness. Her inflammatory markers were significantly increased, and results of a urinalysis were normal. She was administered broad-spectrum intravenous antibiotics. A provisional diagnosis of perforated appendicitis was made, but after surgical consultation and with normal abdominal ultrasound and computed tomography studies, it was discounted. Findings of the patient’s neurological examination remained normal but in view of persistent back pain and restriction of spinal flexion, magnetic resonance imaging (MRI) of the spine (Fig 1) was performed, which revealed an extensive spinal epidural abscess, with evidence of septic arthritis of T7 facet joint. An urgent neurosurgical consult and drainage of the abscess was performed on the same day. The patient made an excellent recovery and demonstrated normal power and sensation postoperatively. A follow-up MRI 3 weeks later showed resolution of the abscess with persistent signal change of T7/8 facet joint (Fig 2).
Discussion
Spinal epidural abscess is rare in children and usually presents with high-grade fever and spinal pain followed by
* Communications should be addressed to: Dr. Manish Prasad; Department of Paediatrics; Pinderfield General Hospital; Aberford Road;Wakefield, UK; WF1 4DG. E-mail address: [email protected] 0887-8994/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2014.01.034
neurological deterioration. In contrast to adults, only onethird of the children have underlying diseases (e.g., leukemia).1 The most common pathogen is Staphylococcus aureus. The main determinant of prognosis is the patient’s neurological status at the time of diagnosis. Overall, the outcome is much better in children with spinal epidural abscess compared with adults because the pathology in the latter is likely attributable to underlying predisposing disease. In one series of 34 children, none of the children died and neurological sequelae were reported in 18%.1 As this girl illustrates, spinal epidural abscess can masquerade as an “acute surgical abdomen,” and therefore a high degree of suspicion is required once the more common etiologies are eliminated because the outcome is favorable with early recognition. MRI is the optimal diagnostic modality, and management includes antibiotic therapy and surgical drainage. Reference 1. Auletta JJ, John CC. Spinal epidural abscesses in children: a 15-year experience and review of the literature. Clin Infect Dis. 2001;32: 9-16.
M. Prasad, N. De Vere / Pediatric Neurology 50 (2014) 540e541
541
FIGURE 2. Whole-spine T1-weighted magnetic resonance imaging with contrast 3 weeks after surgery showing complete resolution of epidural abscess. Arrow shows the site of surgical drainage. FIGURE 1. Whole-spine T1-weighted magnetic resonance imaging with contrastextensive epidural collection extending from T5 to L3 (small white arrowheads) in the posterior aspect of the spinal canal with multiple loculations (black arrows). Spinal cord (long white arrow) is markedly compressed anteriorly from T7 to the conus but is of normal signal.
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Visual Diagnosis
Spinal Epidural Abscess Masquerading as an Acute Abdomen Manish Prasad MRCPCH *, Natasha De Vere MRCPCH Department of Paediatrics, Pinderfield General Hospital, Wakefield, UK
Case Summary A previously well 14-year-old girl presented with a 2-day history of fever and worsening abdominal and generalized back pain. She was acutely unwell, requiring fluid resuscitation. Her systemic examination revealed abdominal tenderness with guarding and bilateral renal angle tenderness. Examination of the spine was normal with no bony tenderness. Her inflammatory markers were significantly increased, and results of a urinalysis were normal. She was administered broad-spectrum intravenous antibiotics. A provisional diagnosis of perforated appendicitis was made, but after surgical consultation and with normal abdominal ultrasound and computed tomography studies, it was discounted. Findings of the patient’s neurological examination remained normal but in view of persistent back pain and restriction of spinal flexion, magnetic resonance imaging (MRI) of the spine (Fig 1) was performed, which revealed an extensive spinal epidural abscess, with evidence of septic arthritis of T7 facet joint. An urgent neurosurgical consult and drainage of the abscess was performed on the same day. The patient made an excellent recovery and demonstrated normal power and sensation postoperatively. A follow-up MRI 3 weeks later showed resolution of the abscess with persistent signal change of T7/8 facet joint (Fig 2).
Discussion
Spinal epidural abscess is rare in children and usually presents with high-grade fever and spinal pain followed by
* Communications should be addressed to: Dr. Manish Prasad; Department of Paediatrics; Pinderfield General Hospital; Aberford Road;Wakefield, UK; WF1 4DG. E-mail address: [email protected] 0887-8994/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2014.01.034
neurological deterioration. In contrast to adults, only onethird of the children have underlying diseases (e.g., leukemia).1 The most common pathogen is Staphylococcus aureus. The main determinant of prognosis is the patient’s neurological status at the time of diagnosis. Overall, the outcome is much better in children with spinal epidural abscess compared with adults because the pathology in the latter is likely attributable to underlying predisposing disease. In one series of 34 children, none of the children died and neurological sequelae were reported in 18%.1 As this girl illustrates, spinal epidural abscess can masquerade as an “acute surgical abdomen,” and therefore a high degree of suspicion is required once the more common etiologies are eliminated because the outcome is favorable with early recognition. MRI is the optimal diagnostic modality, and management includes antibiotic therapy and surgical drainage. Reference 1. Auletta JJ, John CC. Spinal epidural abscesses in children: a 15-year experience and review of the literature. Clin Infect Dis. 2001;32: 9-16.
M. Prasad, N. De Vere / Pediatric Neurology 50 (2014) 540e541
541
FIGURE 2. Whole-spine T1-weighted magnetic resonance imaging with contrast 3 weeks after surgery showing complete resolution of epidural abscess. Arrow shows the site of surgical drainage. FIGURE 1. Whole-spine T1-weighted magnetic resonance imaging with contrastextensive epidural collection extending from T5 to L3 (small white arrowheads) in the posterior aspect of the spinal canal with multiple loculations (black arrows). Spinal cord (long white arrow) is markedly compressed anteriorly from T7 to the conus but is of normal signal.