Intramedullary abscess of the cervical spinal cord in an otherwise healthy man

Intramedullary Thoracic Spinal Cord Abscess Mimicking an Intramedullary Tumor: A Case Report

An intramedullary abscess is an extremely rare form of infection of the spinal cord, with only about 100 cases reported in the literature. It typically presents with back pain, neurological deficits, and, occasionally, fever. The purpose of this article is to report a case of an intramedullary thoracic spinal cord abscess that was initially misdiagnosed as an intramedullary tumor. A 48-year-old female presented with chronic inter-scapular pain and lower limb weakness. The patient was initially misdiagnosed as a case of intramedullary spinal cord tumor, primarily due to the rarity of intramedullary spinal cord abscess (ISCA) as well as the absence of ring enhancement in the lesion on MRI. However, during a surgical procedure for the excision of the lesion, it was found to be a case of ISCA. The purulent contents of the lesion were evacuated, and the patient was treated with IV antibiotics, leaving the patient with a slight residual lower limb weakness on the follow-up examination. This case highlights the importance of considering intramedullary abscess as a possible diagnosis in patients with back pain and neurological deficits, even in the absence of ring enhancement on imaging. Prompt surgical intervention should be considered in probable cases of intramedullary spinal cord tumors.

Intramedullary Spinal Cord Abscess with Concomitant Spinal Degenerative Diseases: A Case Report and Systematic Literature Review

Intramedullary spinal cord abscess (ISCA) is a rare clinical pathology of the central nervous system that usually accompanies other underlying comorbidities. Traditionally it has been associated with significant mortality and neurological morbidities because it is often difficult to diagnose promptly, owing to its nonspecific clinical and neuroimaging features. The mortality rate and the outcome of these infections have been improved by the introduction into clinical practice of antibiotics, advanced neuroimaging modalities, and immediate surgery. We report the case of a 65-year-old male patient who presented with a progressive spastic gait and lumbar pain, predominantly in the left leg. An MRI image revealed an expansile intramedullary cystic mass in the thoracic spinal cord, which was initially diagnosed as a spinal tumor. He underwent laminectomy and myelotomy, and eventually the pus was drained from the abscess. The follow-up MRI showed improvement, but the patient’s paraplegia persisted. In light of his persistent hypoesthesia and paraplegic gait with developing neuropathic pain, he was readmitted, and an MRI of his lumbar spine revealed multilevel degenerative disease and tethered spinal cord syndrome with compression of the medulla at the L2–L3 level. The patient underwent central flavectomy with bilateral foraminotomy at the L2–L3 level, and the medulla was decompressed. Postoperatively, his neurological symptoms were significantly improved, and he was discharged from hospital on the third day after admission. In support of our case, we systematically reviewed the recent literature and analyzed cases published between 1949 and May 2022, including clinical features, mechanisms of infection, predisposing factors, radiological investigations, microbial etiologies, therapies and their duration, follow-ups, and outcomes. Initial clinical presentation can be misleading, and the diagnosis can be challenging, because this condition is rare and coexists with other spinal diseases. Hence, a high index of suspicion for making an accurate diagnosis and timely intervention is required to preclude mortality and unfavorable outcomes. Our case is a clear example thereof. Long-term follow-up is also essential to monitor for abscess recurrences.

What Is Currently Known about Intramedullary Spinal Cord Abscess among Children? A Concise Review

Intramedullary spinal cord abscesses (ISCA) are rare. Typical symptoms include signs of infection and neurological deficits. Symptoms among (younger) children can be highly uncharacteristic. Therefore, prompt and proper diagnoses may be difficult. Typical therapeutic options include antibiotics and neurosurgical exploration and drainage. In this review, we analyze published cases of ISCA among children. Most pediatric cases were found to be under the age of 6 years. The typical symptoms included motor deficits in 89.06%, infection signs in 85.94%, and sensory deficits in 39.06%. Urinary dysfunction was observed in 43.75%, and bowel dysfunction in 17.19%. The predisposing factors included dermal sinuses, (epi)dermoid cysts, prior infection, iatrogenic disorder, and trauma. The most common pathogens were: Staphylococcus aureus, Mycobacterium tuberculosis, Escherichia coli, and Proteus mirabilis. The pediatric population has good outcomes as 45.93% of patients had complete neurological recovery and only 26.56% had residual neurological deficits. Fifteen (23.44%) had persistent neurological deficits. Only one (1.56%) patient died with an ISCA. In two (3.13%) cases, there were no details about follow-up examinations.

Spontaneous intramedullary abscesses caused by Streptococcus anginosus: two case reports and review of the literature

BACKGROUND

Intramedullary abscesses are rare infections of the spinal cord. Intramedullary abscesses often have a complex presentation, making a high index of suspicion essential for prompt diagnosis and management.

CASE PRESENTATION

We present two cases of intramedullary abscesses referred to and ultimately managed at our institution. Delayed diagnosis occurred in both instances due to the rarity of intramedullary abscesses and their propensity to mimic other pathologies. For both patients, prompt surgical management and the rapid institution of broad-spectrum antibiotics were critical in preventing further neurological decline.

CONCLUSIONS

Although rare, it is critical to consider intramedullary abscesses on the differential for any MRI lesions that are hyperintense on T2 and peripherally enhancing on T1 post-contrast sequences, as even short delays in treatment can lead to severe neurological damage.

Spinal intramedullary abscess due to Candida albicans in an immunocompetent patient: A rare case report

Background:

A spinal intramedullary abscess is a rare clinical entity in which patients classically present with a subacute myelopathy and progressive paraplegia, sensory deficits, and/or bowel and bladder dysfunction. We report the second case of spinal intramedullary abscess caused by Candida albicans to ever be published and the first case of its kind to be surgically managed.

Case Description:

A 44-year-old female presented with severe lumbar pain associated with paraparesis, incontinence, and paraplegia. She reported multiple hospital admissions and had a history of seizures, having already undergone treatment for neurotuberculosis and fungal infection of the central nervous system unsuccessfully. Nevertheless, no laboratory evidence of immunosuppression was identified on further investigation. Magnetic resonance imaging showed a D10-D11, well-circumscribed, intramedullary mass within the conus, which was hypointense on T1-weighted imaging and hyperintense on T2/STIR weighted. The patient underwent surgery for removal and biopsy of the lesion, which provided the diagnosis of an intramedullary abscess caused by C. albicans, a very rare condition with only one case reported in literature so far.

Conclusion:

C. albicans intramedullary abscess is a very rare clinical entity, especially in immunocompetent patients. We highlight C. albicans as an important etiology that must be considered in differential diagnosis. Critical evaluation of every case, early diagnosis, timely referral and surgical management of the abscess is essential to improve neurological outcome.

Intramedullary tumours and tumour mimics

Spinal cord lesions are traditionally classified as either extradural or intradural extramedullary or of intramedullary origin. Intramedullary spinal cord tumours are histopathologically similar to cranial tumours with a diverse range of pathologies. Astrocytomas and ependymomas account for approximately 80% of all intramedullary tumours, with other primary and secondary lesions accounting for the remaining 20%. Magnetic resonance imaging is the preferred imaging modality for diagnosing and characterising spinal cord lesions; however, accurate characterisation of tumour histology can be challenging, and is further confounded by intramedullary non-neoplastic lesions, such as demyelinating vascular, inflammatory, infectious, or traumatic lesions. This review illustrates the spectrum of intramedullary tumours and tumour mimics with emphasis on the imaging findings.

Intramedullary Cervical Spinal Cord Abscess

Intramedullary spinal cord abscesses are rarely encountered in modern neurosurgical practice. Select patients are at high risk for developing an intramedullary spinal cord abscess, which can result in acute neurologic deficits. Patients with failed conservative management may benefit from early surgical intervention; however, the evidence is limited by level 3 studies. In this case presentation, the patient failed conservative management for a cervical intramedullary spinal cord abscess and developed acute neurologic deficits. The decision was made to perform an urgent cervical laminectomy and drainage to avoid any further decline that may have occurred with continued conservative management. Increased awareness of intramedullary spinal cord abscess is warranted for its clinical suspicion and emergent treatment in select circumstances.

Streptococcus pneumoniae meningitis complicated by an intramedullary abscess: a case report and review of the literature

BACKGROUND

Intramedullary abscess is a rare neurosurgical condition that usually arises in the setting of penetrating trauma to the spinal cord, infected congenital dural sinuses, or tuberculosis.

CASE PRESENTATION

We describe a case of a 35-year-old African American male who presented with sepsis and a clinical picture of meningitis. The patient continued to have declining neurological status with decreasing sensation and worsening motor strength in all four extremities. He was found to have an intramedullary abscess in the cervical spinal cord that was treated with a decompressive posterior cervical laminectomy and drainage. The patient began to have a partial recovery of neurological function postoperatively. We also review the literature on intramedullary abscess that suggests the clinical presentation of our patient was a rare complication of acute meningitis.

CONCLUSIONS

Intramedullary abscess formation is a rare entity, and a high index of suspicion for intramedullary abscess is the key for making the diagnosis and expediting treatment for these patients.

Intramedullary spinal cord abscess and subsequent granuloma formation: a rare complication of vertebral osteomyelitis detected by diffusion-weighted magnetic resonance imaging

An intramedullary spinal cord abscess, which is usually associated with discitis, is an uncommon but potentially important complication of vertebral osteomyelitis. The authors describe a rare case of an intramedullary conus medullaris abscess and lumbar osteomyelitis sparing the intervertebral discs and without discitis. The patient also developed a granuloma in the cauda equina during treatment. Diffusion-weighted MRI was useful for differentiating the granulomatous lesion from the relapse of infection. A 65-year-old immunocompetent man with moderately controlled diabetes presented with progressive lowerextremity numbness and weakness with urinary dysfunction. He had progressive paraparesis, bilateral leg paresthesia, and sphincter compromise. Magnetic resonance imaging revealed an intramedullary ring-enhanced lesion, which was hyperintense on diffusion-weighted images. The lesion, an intramedullary spinal cord abscess, was surgically drained. During antibiotic treatment, serial MRI showed an enlarging enhanced lesion in the cauda equina, and a recurrent infection was suspected. A second-look surgery confirmed the formation of a granuloma and the absence of a relapse of the abscess. Although the enhanced lesion increased in size, its intensity on diffusion-weighted images remained unchanged. After 3 months of antibiotic treatment, all enhanced lesions were diminished. An intramedullary spinal cord abscess is a rare but important complication of vertebral osteomyelitis, and it requires immediate treatment. Diffusion-weighted MRI was useful for the initial diagnosis as well as for monitoring treatment efficacy.