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

Bacterial and Viral Infectious Disease of the Spine

Spinal infections are a diverse group of diseases affecting different compartments of the spine with variable clinical and imaging presentations. Diagnosis of spinal infections is based on a combination of clinical features, laboratory markers, and imaging studies. Imaging plays a pivotal role in the diagnosis and management of spinal infections. The characteristic imaging manifestations of bacterial and viral infections in the spine are discussed with key teaching points emphasized.

Cervical Intramedullary Spinal Cord Abscess Secondary to Discitis and Osteomyelitis in an Immunocompromised Patient

Intramedullary spinal cord abscess is a rare neurological condition, not commonly suspected and often misdiagnosed. Even after a prompt diagnosis and treatment, most patients persist with permanent neurological deficits. In adults, factors such as immunocompromised, intravenous drug use, endocarditis, and sepsis could be associated with its development. In this study, we present the case of a 63-year-old male patient who developed a chronic cervical intramedullary spinal cord abscess after being treated for multiple abscesses in the paravertebral and psoas muscles. A diagnosis of cervical intramedullary spinal cord abscess secondary to osteomyelitis and discitis was made. He underwent a two-stage cervical surgery, with drainage of the abscess, spinal stabilization, and intravenous antibiotics. Although rare, vertebral osteomyelitis and discitis may be related to its development. Early diagnosis, prompt abscess drainage, and appropriate antibiotic therapy are of utmost importance to improve prognosis and minimize the long-term sequelae and complications of permanent neurological deficits.

Case Report: A rare case of intramedullary spinal cord abscess with brain abscess caused by Klebsiella pneumoniae underwent surgical intervention

Background

Intramedullary Spinal Cord Abscess (ISCA) is an uncommon infectious disease of the central nervous system. Since its first report in 1830, there have been very few documented cases associated with it. Here, we present a case of ISCA with cerebral abscess caused by Klebsiella pneumoniae.

Case presentation

A 55-year-old male patient presented with head and neck pain, fever, and left limb weakness for 5 days. The diagnosis of ISCA with brain abscess caused by Klebsiella pneumoniae was confirmed through sputum culture, cerebrospinal fluid gene test, pus culture, and magnetic resonance imaging (MRI) as well as computerized tomography (CT) scan. The patient had a history of pulmonary tuberculosis and old tuberculous foci were observed in the lung. Initially considering tuberculosis as the cause due to unclear etiology at that time, anti-tuberculosis treatment was administered. However, due to rapid deterioration in the patient's condition and severe neurological dysfunction within a short period of time after admission, surgical intervention including incision and drainage for intramedullary abscess along with removal of brain abscess was performed. Subsequent postoperative follow-up showed improvement in both symptoms and imaging findings.

Conclusion

Early diagnosis of central nervous system (CNS) abscess coupled with prompt surgical intervention and administration of appropriate antibiotics are crucial factors in preventing disease progression and reducing mortality rates.

Intramedullary spinal cord abscess involving Actinomyces and Streptococcus: a case report and literature review

INTRODUCTION

Intramedullary spinal cord abscesses (ISCA) are rare and caused by central nervous system infections. Although polymicrobial infections are rarely seen in ISCAs, isolation of the causative pathogen is important for treatment. Here, we describe a very rare case of ISCA resulting from a mixed Streptococcus and Actinomyces infection.

CASE PRESENTATION

An 82-year-old man presented with acute posterior cervical pain and progressive quadriplegia. Radiological investigations revealed a mass lesion showing marginal enhancement at the level of the C3-4 vertebrae. Microsurgical drainage was performed, and Streptococcus and Actinomyces were identified as causative agents. Subsequent antibiotic treatment was noted to be beneficial to the patient.

DISCUSSION

This case suggests that mixed infection can develop into ISCA depending on the causative agents such as Actinomyces. Prompt pathogen-directed antibacterial therapy is required for ISCA treatment.

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 brain abscess due to subacute infective endocarditis

BACKGROUND

Intramedullary spinal cord abscesses (ISCA) are rare, even more so in association with brain abscesses. Infective endocarditis is an uncommon cause of ISCA. In this case study, we report a patient with intramedullary abscesses and multiple brain abscesses due to subacute infective endocarditis.

CASE PRESENTATION

A 54-year-old man presented with a 7-day history of head and neck pain and numbness in both lower limbs. Intramedullary abscess combined with multiple brain abscesses was diagnosed based on blood culture, head and spinal magnetic resonance imaging (MRI), contrast-enhanced MRI, and magnetic resonance spectroscopy. Echocardiography revealed vegetations on the mitral valve and severe mitral regurgitation, which the authors believe was caused by subacute infective endocarditis. With ceftriaxone combined with linezolid anti-infective therapy, the patient's symptoms and imaging was improved during follow-up.

CONCLUSIONS

This case hopes to raise the vigilance of clinicians for ISCA. When considering a patient with an ISCA, it is necessary to complete blood culture, MRI of the brain and spinal cord, and echocardiography to further identify whether the patient also has a brain abscess and whether the cause is infective endocarditis.

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.