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Unusual cervical spine epidural abscess
American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Unusual cervical spine epidural abscess Abstract A 48-year-old man presented to the emergency department with complain of severe neck pain and anterior chest pain. Intermittent fever in the recent 2 days was also noted. There is a track maker over his left side of neck. The laboratory examination showed leukocytosis and high C-reactive protein level. Urine drug screen was positive for opiate. Empirical antibiotic administration was given. Blood culture grew gram-positive cocci in chain, and there was no vegetation found by heart echocardiogram. However, progressive weakness of four limbs was noted, and patient even cannot stand up and walk. The patient also complained of numbness sensation over bilateral hands and legs, and lower abdomen. Acute urine retention occurred. We arranged magnetic resonance imaging survey, which showed evidence of inflammatory process involving the retropharyngeal spaces and epidural spaces from the skull base to the bony level of T5. Epidural inflammatory process resulted in compression of the spinal cord and bilateral neural foramen narrowing. Neurosurgeon was consulted. Operation with laminectomy and posterior fusion with bone graft and internal fixation was done. Culture of epidural abscess and 2 sets of blood culture all yielded methicillin-sensitive Staphylococcus aureus. For epidural abscess, the most common involved spine is lumbar followed by thoracic and cervical spine. Diagnosis and treatment in the drug abusers are still challenging because they lack typical presentation, drug compliance, and adequate follow-up and because it is hard to stop drug abuser habit. Significant improvement of neurological deficit can be expected in most spinal abscess in drug abusers after treatment. Spinal infections were seldom seen in the past. In recent years, the increasing rate of intravenous drug abuse makes more spinal infection cases [1]. The most common symptoms include fever, backache, and neurological deficit [2]. Their insidious presentation easily leads to delay in diagnosis and difficulty in treatment. Here, we present a rare case of a drug abuser who progressed to epidural abscess after intramuscularly injected opiate drug in his neck. A 48-year-old man had no history of systemic disease before, and he was an opiate drug abuser. He presented to the emergency department with complain of severe neck pain and anterior chest pain. Intermittent fever in recent 2 days was also noted. On physical examination, his body temperature was 37.1°C; pulse rate was 79 beats per minute; respiratory rate was 22 breaths per minute; and blood pressure was 158/74 mm Hg. There is a track maker over the left side of his neck (Fig. 1). He confessed that he injected drug there and made the wound. The laboratory examination showed leukocytosis (20,300/μL) and high C-reactive protein (20.41 mg/dL) level. Urine drug screen was positive for opiate. Empirical antibiotic administration with cefpirome 2 g every 12 hours and teicoplanin 400 mg per day was given. Blood culture grew gram-positive cocci in chain, and there was no vegetation found by heart echocardiogram.
However, progressive weakness of four limbs was noted, and the patient even cannot stand up and walk. He also complained of numbness sensation over bilateral hands and legs, and lower abdomen. Acute urine retention occurred. Under the suspicion of cervical myelopathy, we arranged magnetic resonance imaging survey. Magnetic resonance images showed evidence of inflammatory process involving the retropharyngeal spaces and epidural spaces from the skull base to the bony level of T5. Epidural inflammatory process resulted in compression of the spinal cord and bilateral neural foramen narrowing (Fig. 2A and B). Neurosurgeon was consulted. Operation with laminectomy and posterior fusion with bone graft and internal fixation was done. Culture of epidural abscess and 2 sets of blood culture all yielded methicillinsensitive Staphylococcus aureus. Spinal infections are uncommon and accounted for 2% to 4% of bone infections [2]. It can be divided into discitis, spondylitis, and spondylodiscitis with/without epidural abscess. Some comorbidities such as old age, diabetes mellitus, immunocompromised status (steroid use, human immunodeficiency infection, chronic renal failure), alcoholism, malignancy, and intravenous drug abuse are vulnerable to spinal infection [1–4]. Drug abusers have a higher occurrence rate of spinal infection owing to risk of local or systemic infection. The incidence rate is about 0.5 to 2.2 per 100,000 cases [1]. In the past, spinal infection is more prevalent in fifth and sixth decades of age. However, drug abusers with spinal infection are younger than ordinary cases of spinal infection. The average age is about the fourth decade of age [1, 2]. Backache is a reliable presentation of spinal infection in drug abusers. The most common involved spine in epidural abscess is lumbar, followed by thoracic and cervical spine. Most patients affected only single level; multiple level involvements were less conditions [1, 2]. However, our patient suffered from multiple cervical spine involvement. The mean white cell count is 11,100/μL, and C-reactive protein is 6.7 mg/dL. In our case, the laboratory data were higher than the mean levels in published literature. We isolated methicillin-sensitive S aureus in abscess and blood culture, which is the most common pathogen in drug abusers. The goal of management is limited damage and preserving the neurological function [3]. The management consists of parenteral antibiotics administration for 6 to 8 weeks and surgical debridement for decompression. Conservative treatment with parenteral antibiotics administration will be successful in the treatment of majority of cases. If acute neurological deficit happened or medical treatment failed, surgical intervention should be considered in these minority cases [1–4]. Drug abuse is a serious public health problem; it may lead to several infectious diseases and complications. Diagnosis and treatment in drug abusers are still challenging because they lack typical presentation, drug compliance, and adequate follow-up and because it is hard to stop drug abuser habit. Significant improvement of neurological deficit can be expected in most spinal abscesses in drug abusers after treatment.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Liou J-H, Unusual cervical spine epidural abscess, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.07.052
2
J-H. Liou, . / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Yu-Jang Su MD Department of Emergency Medicine, Mackay Memorial Hospital Taipei, Taiwan Department of Oral Hygiene, College of Oral Medicine Taipei Medical University, Taipei, Taiwan Department of Medicine, Mackay Medical College, New Taipei City, Taiwan Mackay Junior College of Medicine, Nursing, and Management Corresponding author. Department of Emergency Medicine Mackay, Memorial Hospital, Taipei 10449, Taiwan and Department of Oral Hygiene, College of Oral Medicine Taipei Medical University, Taipei, Taiwan Tel.: +886 2 25433535x3126; fax: +886 2 27621403 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2015.07.052 References
Fig. 1. Local injection wound was noted in left side of neck (black arrow key).
Jr-Han Liou MD Department of Emergency Medicine, Mackay Memorial Hospital Taipei, Taiwan
[1] Ziu M, Dengler B, Cordell D, Bartanusz V. Diagnosis and management of primary pyogenic spinal infections in intravenous recreational drug users. Neurosurg Focus 2014; 37(2):E3. [2] Chuo CY, Fu YC, Lu YM, Chen JC, Shen WJ, Yang CH, et al. Spinal infection in intravenous drug abusers. J Spinal Disord Tech 2007;20(4):324–8. [3] Wang Z, Lenehan B, Itshayek E, Boy M, Dvorak M, Fisher C, et al. Primary pyogenic infection of the spine in intravenous drug users: a prospective observational study. Spine (Phila Pa 1976) 2012;37(8):685–92. [4] Tunkel AR, Pradhan SK. Central nervous system infections in injection drug users. Infect Dis Clin North Am 2002;16(3):589–605.
Fig. 2. A and B, Abnormal high signal intensity in C2 to C7 in T1 with contrast image suggested inflammatory process involving the retropharyngeal spaces, epidural spaces, and cervical spine (white arrow). Abnormal enhancement in spinal cord from bone level of C2 to C7 in T2 image suggested myelopathy (white arrow).
Please cite this article as: Liou J-H, Unusual cervical spine epidural abscess, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.07.052
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Unusual cervical spine epidural abscess Abstract A 48-year-old man presented to the emergency department with complain of severe neck pain and anterior chest pain. Intermittent fever in the recent 2 days was also noted. There is a track maker over his left side of neck. The laboratory examination showed leukocytosis and high C-reactive protein level. Urine drug screen was positive for opiate. Empirical antibiotic administration was given. Blood culture grew gram-positive cocci in chain, and there was no vegetation found by heart echocardiogram. However, progressive weakness of four limbs was noted, and patient even cannot stand up and walk. The patient also complained of numbness sensation over bilateral hands and legs, and lower abdomen. Acute urine retention occurred. We arranged magnetic resonance imaging survey, which showed evidence of inflammatory process involving the retropharyngeal spaces and epidural spaces from the skull base to the bony level of T5. Epidural inflammatory process resulted in compression of the spinal cord and bilateral neural foramen narrowing. Neurosurgeon was consulted. Operation with laminectomy and posterior fusion with bone graft and internal fixation was done. Culture of epidural abscess and 2 sets of blood culture all yielded methicillin-sensitive Staphylococcus aureus. For epidural abscess, the most common involved spine is lumbar followed by thoracic and cervical spine. Diagnosis and treatment in the drug abusers are still challenging because they lack typical presentation, drug compliance, and adequate follow-up and because it is hard to stop drug abuser habit. Significant improvement of neurological deficit can be expected in most spinal abscess in drug abusers after treatment. Spinal infections were seldom seen in the past. In recent years, the increasing rate of intravenous drug abuse makes more spinal infection cases [1]. The most common symptoms include fever, backache, and neurological deficit [2]. Their insidious presentation easily leads to delay in diagnosis and difficulty in treatment. Here, we present a rare case of a drug abuser who progressed to epidural abscess after intramuscularly injected opiate drug in his neck. A 48-year-old man had no history of systemic disease before, and he was an opiate drug abuser. He presented to the emergency department with complain of severe neck pain and anterior chest pain. Intermittent fever in recent 2 days was also noted. On physical examination, his body temperature was 37.1°C; pulse rate was 79 beats per minute; respiratory rate was 22 breaths per minute; and blood pressure was 158/74 mm Hg. There is a track maker over the left side of his neck (Fig. 1). He confessed that he injected drug there and made the wound. The laboratory examination showed leukocytosis (20,300/μL) and high C-reactive protein (20.41 mg/dL) level. Urine drug screen was positive for opiate. Empirical antibiotic administration with cefpirome 2 g every 12 hours and teicoplanin 400 mg per day was given. Blood culture grew gram-positive cocci in chain, and there was no vegetation found by heart echocardiogram.
However, progressive weakness of four limbs was noted, and the patient even cannot stand up and walk. He also complained of numbness sensation over bilateral hands and legs, and lower abdomen. Acute urine retention occurred. Under the suspicion of cervical myelopathy, we arranged magnetic resonance imaging survey. Magnetic resonance images showed evidence of inflammatory process involving the retropharyngeal spaces and epidural spaces from the skull base to the bony level of T5. Epidural inflammatory process resulted in compression of the spinal cord and bilateral neural foramen narrowing (Fig. 2A and B). Neurosurgeon was consulted. Operation with laminectomy and posterior fusion with bone graft and internal fixation was done. Culture of epidural abscess and 2 sets of blood culture all yielded methicillinsensitive Staphylococcus aureus. Spinal infections are uncommon and accounted for 2% to 4% of bone infections [2]. It can be divided into discitis, spondylitis, and spondylodiscitis with/without epidural abscess. Some comorbidities such as old age, diabetes mellitus, immunocompromised status (steroid use, human immunodeficiency infection, chronic renal failure), alcoholism, malignancy, and intravenous drug abuse are vulnerable to spinal infection [1–4]. Drug abusers have a higher occurrence rate of spinal infection owing to risk of local or systemic infection. The incidence rate is about 0.5 to 2.2 per 100,000 cases [1]. In the past, spinal infection is more prevalent in fifth and sixth decades of age. However, drug abusers with spinal infection are younger than ordinary cases of spinal infection. The average age is about the fourth decade of age [1, 2]. Backache is a reliable presentation of spinal infection in drug abusers. The most common involved spine in epidural abscess is lumbar, followed by thoracic and cervical spine. Most patients affected only single level; multiple level involvements were less conditions [1, 2]. However, our patient suffered from multiple cervical spine involvement. The mean white cell count is 11,100/μL, and C-reactive protein is 6.7 mg/dL. In our case, the laboratory data were higher than the mean levels in published literature. We isolated methicillin-sensitive S aureus in abscess and blood culture, which is the most common pathogen in drug abusers. The goal of management is limited damage and preserving the neurological function [3]. The management consists of parenteral antibiotics administration for 6 to 8 weeks and surgical debridement for decompression. Conservative treatment with parenteral antibiotics administration will be successful in the treatment of majority of cases. If acute neurological deficit happened or medical treatment failed, surgical intervention should be considered in these minority cases [1–4]. Drug abuse is a serious public health problem; it may lead to several infectious diseases and complications. Diagnosis and treatment in drug abusers are still challenging because they lack typical presentation, drug compliance, and adequate follow-up and because it is hard to stop drug abuser habit. Significant improvement of neurological deficit can be expected in most spinal abscesses in drug abusers after treatment.
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Liou J-H, Unusual cervical spine epidural abscess, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.07.052
2
J-H. Liou, . / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Yu-Jang Su MD Department of Emergency Medicine, Mackay Memorial Hospital Taipei, Taiwan Department of Oral Hygiene, College of Oral Medicine Taipei Medical University, Taipei, Taiwan Department of Medicine, Mackay Medical College, New Taipei City, Taiwan Mackay Junior College of Medicine, Nursing, and Management Corresponding author. Department of Emergency Medicine Mackay, Memorial Hospital, Taipei 10449, Taiwan and Department of Oral Hygiene, College of Oral Medicine Taipei Medical University, Taipei, Taiwan Tel.: +886 2 25433535x3126; fax: +886 2 27621403 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.ajem.2015.07.052 References
Fig. 1. Local injection wound was noted in left side of neck (black arrow key).
Jr-Han Liou MD Department of Emergency Medicine, Mackay Memorial Hospital Taipei, Taiwan
[1] Ziu M, Dengler B, Cordell D, Bartanusz V. Diagnosis and management of primary pyogenic spinal infections in intravenous recreational drug users. Neurosurg Focus 2014; 37(2):E3. [2] Chuo CY, Fu YC, Lu YM, Chen JC, Shen WJ, Yang CH, et al. Spinal infection in intravenous drug abusers. J Spinal Disord Tech 2007;20(4):324–8. [3] Wang Z, Lenehan B, Itshayek E, Boy M, Dvorak M, Fisher C, et al. Primary pyogenic infection of the spine in intravenous drug users: a prospective observational study. Spine (Phila Pa 1976) 2012;37(8):685–92. [4] Tunkel AR, Pradhan SK. Central nervous system infections in injection drug users. Infect Dis Clin North Am 2002;16(3):589–605.
Fig. 2. A and B, Abnormal high signal intensity in C2 to C7 in T1 with contrast image suggested inflammatory process involving the retropharyngeal spaces, epidural spaces, and cervical spine (white arrow). Abnormal enhancement in spinal cord from bone level of C2 to C7 in T2 image suggested myelopathy (white arrow).
Please cite this article as: Liou J-H, Unusual cervical spine epidural abscess, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.07.052