Listeria spinal cord abscess--clinical and MRI findings

Computed tomography and magnetic resonance imaging findings in central nervous system listeriosis

PURPOSE

To describe the imaging findings and determine the incidence of a characteristic worm-like pattern along the white matter tracts in neurolisteriosis on CT/MRI.

METHODS

An IRB-approved retrospective study in 21 consecutive neurolisteriosis cases during January 2002-July 2020. At least one of the following is required: (1) Positive Listeria monocytogenes (LM) in blood with clinical signs of meningeal irritation and/or abnormal CSF profile, (2) positive LM in blood with signs of encephalitis, (3) positive LM in CSF, (4) positive LM from brain biopsy/aspiration. Six cases were excluded due to the lack of contrast-enhanced images, leaving a total of 15 cases for analysis (mean age 53.5 years ± 18.8 SD). The imaging studies were independently reviewed by two blinded readers. Demographic data, imaging findings, and incidence of the worm-like pattern were reported. The Cohen's kappa was used to calculate interrater reproducibility.

RESULTS

Of the 12 patients with relevant imaging findings, nine cases (75%) had parenchymal lesions (eight cases in supratentorial compartment and one case in infratentorial compartment), four cases (33.3%) had leptomeningeal enhancement and two cases (16.7%) had hydrocephalus. Brain abscesses were found in eight cases and nodules evocative of abscess in one case. Restricted diffusion in the central area and hemosiderin deposition were observed in all cases. The involvement of white matter tract in a worm-like pattern was demonstrated in eight of nine patients with parenchymal lesions (88.9%).

CONCLUSION

Abnormal findings in brain CT/MRI images are common in neurolisteriosis. The incidence of worm-like spread along the white matter tracts is high and may help diagnose suspicious patients.

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.

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.

Bacterial infections of the central nervous system

Bacterial CNS infections comprise a wide spectrum of diseases, which may be acquired outside or inside the hospital, affect immunocompetent or immunocompromised patients, and be associated with trauma or procedures, as well as other exposures.

Clues to diagnosing culture negative Listeria rhombencephalitis

A previously healthy 35-year-old Caucasian woman developed left body (including facial) hemianaesthesia, asymmetrical lower cranial nerve palsies and cerebellar signs after a 4-day history of headache, nausea and vomiting. Serial blood and cerebrospinal fluid (CSF) cultures returned negative for a culprit organism. CSF examination revealed a lymphocytic pleocytosis and an elevated protein count. CSF cytological examination identified plasma cells. MRI of brain showed multiple ring-enhancing 'abscess-like' lesions in the brainstem and upper cervical cord together with abnormal meningeal enhancement. A decision was made to treat her empirically for Listeria rhombencephalitis to which she responded completely. CSF PCR eventually returned positive for Listeria monocytogenes. This case illustrates the utility of clinical features, MRI, CSF cytology and PCR in diagnosis and treatment of culture negative L monocytogenes rhombencephalitis in an immunocompetent individual.

Acute onset intramedullary spinal cord abscess with spinal artery occlusion: a case report and review

Intramedullary spinal cord abscess (ISCA) without meningitis is an extremely rare entity in the central nervous system, and it is often difficult to diagnose immediately, and no definitive imaging findings have been established. We experienced the case of a 61-year-old male who presented with a sudden onset back pain without fever following rapidly worsening paraparesis for 3 days, who subsequently become unable to walk. According to the initial MRI and 3D-CTA, the presumptive diagnosis was spinal infarction due to spinal artery embolism. However, his symptoms did not improve, despite the gradual changes in MRI following antiplatelet therapy. He underwent a biopsy in an attempt to prevent the lesion from progressing toward the upper spinal cord. The pathological examination revealed an intramedullary abscess, so we performed a midline myelotomy and drained the pus from the abscess. After surgery, MRI showed improvement, but the patient's paraplegia persisted. To the best of our knowledge, this is the first case report of spinal cord abscess with the confirmation of spinal artery occlusion on angiography, which could have been caused by a bacterial embolism. We herein discuss its possible etiology and also review recent reports on ISCA.

Listeria spinal cord abscess responsive to trimethoprim-sulfamethoxazole monotherapy

OBJECTIVE

To describe an alternative antibiotic regimen for the treatment of central nervous system Listeria monocytogenes infection.

BACKGROUND

Classical treatment of listeria infections of the brain and spinal cord has included ampicillin in combination with gentamicin and chloramphenicol. Antibiotic resistance to L. monocytogenes is extraordinarily low, and the combined risks of nephrotoxicity, ototoxicity, and agranulocytosis in an already critically ill patient make the potential use of trimethoprim-sulfamethoxazole monotherapy for coverage or treatment of listeria an important alternative.

METHODS

Case report.

RESULTS

A 58-year-old woman presented with a two-week history of progressive quadriplegia. Gadolinium enhanced MRI showed diffuse edema of the cervical and thoracic spine with ring-enhancing lesions. Cerebrospinal fluid and blood cultures both grew L. monocytogenes. Spinal cord biopsy of the lesion revealed inflammation with necrosis and also grew listeria. Intravenous trimethoprim-sulfamethoxazole (8 mg/kg in four divided doses) was administered for six weeks with resultant arrest of neurological symptoms and stabilization of the clinical course. Although the patient was quadraparetic she was able to be discharged to a rehabilitation facility.

CONCLUSIONS

Trimethoprim-sulfamethoxazole monotherapy may be a potential alternative option for critically ill patients with central nervous system L. monocytogenes infection.