Epidural abscess in an infant

Abstract

A previously well 2-year-old female infant was admitted as an emergency with status epilepticus. She was apyrexial and general examination was unremarkable. Initial investigation revealed profound hypoglycaemia (glucose < 0.6 mmol/l). The seizures settled following administration of anticonvulsant medication and intravenous glucose. She remained comatose for 24 h. Mid-Chain Acyl-CoA Dehydrogenase Deficiency (MCAD) was suspected, and later confirmed on blood tests. Following the intravenous administration of L-carnitine she became more alert and responsive. At that stage she had an extensor response to painful stimuli with generalised spasticity. Electroencephalogram tests revealed a diffuse encephalopathy.Ten days after admission she developed a pyrexia of 38.4°C; blood cultures were negative. Further pyrexial episodes continued over the next 2 weeks, at the end of which she developed a varicella infection. The skin vesicles became secondarily infected with Staphylococcus aureus, which progressed to a septicaemia and pneumonitis. Her condition deteriorated; although her white cell count was elevated at 16.1 × 10 9 /l, she was profoundly neutropoenic (1.0 × 10 9 /l). Scalp and praecordial abscesses erupted and required formal surgical drainage.Immediately after the above operation there was no voluntary movement of the lower limbs. She had a pyrexia of 39°C and neurological examination showed absent deep tendon reflexes and bilaterally positive Babinski reflexes. Her general condition was poor with inspiratory stridor and low blood saturation even with supplemental oxygen. Plain radiographs were initially interpreted as normal; in retrospect the lateral radiograph of the thoracic spine showed a kyphosis between T5 and T7 (Fig. 1). MRI revealed complete vertebral collapse of T6 and localised kyphosis at this level. There was an extensive epidural abscess and extrusion of granulation tissue posteriorly causing predominant anterior compression of the spinal cord. There was marked marrow oedema of the adjacent vertebrae (Fig. 2).Despite her condition (ASA grade 4), surgery was deemed necessary but was delayed for 12 h for further resuscitation and chest physiotherapy.A left thoracotomy was performed and the MRI findings were confirmed. There was marked paravertebral thickening of the somatic pleura. Frank pus was obtained from within the canal. Decompression of the cord was achieved by means of a T6 vertebrectomy. A rib strut graft was used to maintain correction of the kyphosis. Confirmatory cultures of Staphylococcus aureus were obtained from the intraoperative specimens.Post-operatively she was transferred to the paediatric intensive care unit. High-dose intravenous flucloxacillin, fucidin and gentamicin antibiotic therapy was commenced. The pyrexia rapidly settled and she was successfully weaned from assisted ventilation at 48 h. Spontaneous movements of the legs returned 5 days after the spinal surgery. Oral antibiotic treatment was maintained for 6 weeks. A moulded polypropylene thoracolumbar support orthosis w...

Spinal epidural abscess following blunt pelvic trauma

“…1) and the initial CT scan did not give any evidence of intraspinal pathology -which may, however, not have been present at the stage of the initial scan. Myelography was not necessary for diagnosis, and we agree with other authors on MRI having taken over the position of radiologic procedure of choice [1,3,5,6]. The intraoperative samples proved Staphylococcus aureus to be the pathogen, as in most cases [1, 3-5, 7-9, 12].…”

Pediatric Spinal Epidural Abscess: A 9-Year Institutional Review and Review of the Literature

“…Diagnosis in children is especially challenging because of nonspecific symptoms and frequently delayed until neurologic symptoms develop. [11][12][13] The diagnosis is based on clinical suspicion, increasedinflammatorymarkers, and neurologic imaging. 10 Hematogenous spread is the most common cause of infection in children as supported by the 6 positive blood cultures in our cohort.…”

“…2 The most common organism causing pediatric SEA is S aureus. 2,4,7,9,11,12,16,17,[19][20][21][22] There is increasing prevalence of community-acquired MRSA infections in children without risk factors. 23,24 A thorough literature review performed by Auletta et al indicates high rates of methicillin-sensitive S aureus, in contrast to our review in which the 6 culturepositive patients grew MRSA, reinforcing the changing prevalence and invasiveness community-acquired MRSA can display.…”

Group A Streptococcus Spinal Epidural Abscess During Varicella

“…9,11,13,14 The primary focus for our cases was probably the pharyngitis (throat culture positive in 2 of 2 patients) because there was no evidence of skin superinfection.…”

“…11 Her skin lesions became secondarily infected with S aureus, with associated septicemia and pneumonitis. Skin abscesses were incised and drained and grew S aureus.…”