Spinal Epidural Abscess in Children: Case Report and Review of the Literature

Cryptogenic Epidural Cervicothoracic Abscess: A Case Report and Literature Review

A spinal epidural abscess (SEA) is a rare infection characterized by pus formation in the spinal epidural space, associated with various degrees of motor, sensory, or combined deficits. It is linked to several risk factors and predominantly impacts middle-aged men. This report discusses an atypical case of a patient without any predisposing factors who developed a cervicothoracic SEA associated with significant transverse myelitis. A targeted literature search was conducted on PubMed, Scopus, and SpringerLink, employing terms such as "spinal epidural abscess, subdural empyema, and transverse myelitis." While there are numerous studies on this topic with a multidisciplinary approach, reports of cryptogenic SEA associated with the extensive involvement of cervical and thoracic spinal segments are rare. SEA is a very uncommon condition. Hence, a comprehensive understanding of its clinical presentation is crucial for adopting an appropriate diagnostic approach and delivering timely treatment.

Silent spinal epidural abscess due to facet joint arthritis

Spinal epidural abscess (SEA) is an abscess that forms between the dura mater and vertebrae. SEA is characterized by back pain and neuropathy associated with fever, of which early diagnosis and treatment are necessary to avoid irreversible neurological sequelae. However, its diagnosis is often difficult because specific symptoms are rarely present in the early stages of the disease. A 25-month-old boy, healthy by nature and free of risk factors, was referred and admitted for fever symptoms only, without back pain or neurological symptoms. We focused on the residual activation of the coagulation-fibrinolytic system, which was contrary to the response to therapy, and were able to establish a diagnosis of SEA. After the initiation of antibiotics, the patient responded well to treatment and made a mild recovery without the need for surgical intervention. To date, there are no reported cases of SEA with only febrile symptoms without localized spinal cord tenderness. SEA is easily overlooked and should be considered in the differential diagnosis of pediatric fever of unknown origin. Although imaging studies have drawbacks, such as radiation exposure and sedation, they should be immediately performed if SEA is suspected.

Disseminating MSSA Infection in a Preterm Infant With Rare Finding of Spinal Epidural Abscess: A Case Report

BACKGROUND

Methicillin-susceptible Staphylococcus aureus (MSSA) occurs more frequently in the neonatal intensive care unit (NICU) than methicillin-resistant S. aureus (MRSA) and can result in comparable morbidity and mortality in the neonatal population. MSSA infection may present as pustulosis or cellulitis and evolve into bacteremia, pneumonia, endocarditis, brain abscesses, and osteomyelitis. There is a paucity of literature regarding the treatment and long-term outcomes in the premature infant.

CLINICAL FINDINGS

A 32-week twin developed MSSA sepsis with presentation of pain, decreased movement of upper extremities, and global hypotonia. Blood cultures remained positive despite antibiotic coverage.

PRIMARY DIAGNOSIS

The infant was admitted to the level IV NICU with the diagnosis of MSSA bacteremia, with concern for dissemination and osteomyelitis.

INTERVENTIONS

Diagnostic studies included laboratory testing for sepsis evaluation, radiologic studies to evaluate for dissemination, immunologic testing to rule out complement deficiency, and hematology testing to rule out hypercoagulable conditions.

OUTCOMES

Diagnostic testing showed extensive cellulitis, osteomyelitis, multiple liver abscesses, and epidural abscesses suggestive of spinal epidural abscess (SEA). Abscess debridement and irrigation on the left distal femur, left elbow, and right tibia were performed. The infant completed 8 weeks of IV antibiotic therapy. Immunologic and hematology testing was within normal limits.

PRACTICE RECOMMENDATIONS

Prompt recognition and follow-up for clinical signs of sepsis are vital when caring for premature infants. Inclusion of pediatric subspecialist recommendations to assure all diagnostic studies and treatments are completed can significantly impact the patient's outcome. Long-term follow-up is needed for premature infants with the diagnosis of SEA.

Spontaneous spinal epidural abscess in an adolescent patient: A case report and literature review

INTRODUCTION

Spinal epidural abscess (SEA), particularly the spontaneous variant, is a severe and rare condition often associated with vertebral osteomyelitis, hematogenous infections, and spinal interventions, leading to severe neurological damage and disabilities. Although more common in adults, spontaneous SEA (SSEA) in adolescents is extremely rare but represents a significant risk, as presented here.

PRESENTATION OF CASE

A 16-year-old boy presented with progressive back pain, uncontrolled fever, and paresthesia in the right lower extremity. Despite the absence of common risk factors, SEA was diagnosed at the L4-L5 level. Laboratory results revealed leukocytosis and elevated levels of inflammatory markers. Magnetic resonance imaging (MRI) confirmed the diagnosis of SEA, and surgery revealed Group A Streptococcus in the abscess. The patient showed significant improvement after laminectomy and a six-week course of intravenous cefazolin.

DISCUSSION

SSEA often presents with nonspecific symptoms, leading to delayed diagnosis and treatment. The gold standard for diagnosis is MRI, and typical treatment involves antibiotic administration and surgical decompression. The importance of maintaining a high index of suspicion for SEA in adolescent patients presenting with back pain and fever, even in the absence of common risk factors or sources, is highlighted.

CONCLUSION

We report the infrequent manifestation of SEA in an adolescent patient, and the difficulties in the diagnosis and treatment thereof. Despite these common risk factors, SEA should be considered as a differential diagnosis in adolescents with back pain and uncontrolled fever. Prompt diagnosis, early surgical intervention, and appropriate antimicrobial therapy are vital to improve patient outcomes and prognosis.

Successful Treatment of Pediatric Holo-Spinal Epidural Abscess With Percutaneous Drainage

Spinal epidural abscess (SEA) is a rare and potentially devastating neurologic disease that is commonly treated with neurosurgical decompression and evacuation. We describe the case of an 11-month-old immunocompetent infant who presented with a large multiloculated methicillin-resistant Staphylococcus aureus abscess in the left lung apex with likely mediastinal involvement, extending into the epidural space from C7 down to L2 causing cord compression which was successfully treated with percutaneous placement of an epidural drainage catheter and antibiotic therapy. Although there are rare reports of percutaneous drainage of SEAs, to our knowledge, there are no reports of successful use of percutaneous indwelling catheters resulting in the complete resolution of an SEA. Holo-spinal epidural abscess in an infant is an extremely rare disease with limited literature available regarding the best practice for its treatment. Multiple considerations must be taken into account when weighing the different treatment options ranging from surgical decompression to conservative management with antibiotic therapy. We present a unique case of successful treatment with percutaneous epidural drain placement. This provides a reasonable alternative for management in children for whom surgical decompression carries multiple risks for complications both acutely and delayed.

Pediatric spinal infection with epidural abscess: A report of two cases

Background

Pediatric spinal infections are rare and often accompanied by abscesses. Delayed diagnosis commonly leads to a poor neurological prognosis, emphasizing the need for early diagnosis and treatment.

Case Description

We report on two cases of spinal infection; one in a 5-year-old boy with a T8-11 epidural abscess and one in a 10-year-old boy with an L5-S1 epidural abscess. Both cases improved with conservative therapy.

Conclusion

Early magnetic resonance imaging diagnosis and systemic treatment in collaboration with pediatricians are key factors in the successful management of children with spinal infections.

Spinal epidural abscess in children: a case-based review

BACKGROUND

Pediatric spinal epidural abscess is a major suppurative infection of the central nervous system. It is an extremely rare pathology carrying serious risk of permanent neurological sequelae if is not properly treated.

METHODS AND RESULTS

All the pertinent literature was analyzed, focused on pediatric cases of spinal epidural abscess and its peculiar features. Two illustrative cases are also presented. The first case is that of a 9-year old girl who took medical attention, when she was already paraplegic. Despite prompt surgical evacuation and good neuroradiological outcome and intensive rehabilitation, motor deficits did not recover after surgery. The second case was that of a 14-year old girl who presented with fever, neck pain, and torticollis. Prompt diagnosis, decompressive surgery, and 6 weeks of antibiotics allowed good neurological outcome.

CONCLUSIONS

The management of spinal epidural abscess includes evacuation of the abscess with decompression of the spinal cord and prolonged antibiotic treatment. The presence of neurological deficit and the delay in the initiation of proper treatment are the two factors that more worsen prognosis.