A Good Short-term Outcome in Delayed Decompression of Cauda Equina Syndrome in Klebsiella pneumoniae Spinal Epidural Abscess: A Case Report

Complete Spinal Cord Injury Secondary to Serratia marcescens Spinal Epidural Abscess: A Report of Significant Neurological Improvement After a Delayed Presentation

The exact time at which neurological deficits secondary to a spinal cord injury (SCI) become permanent is unknown. However, urgent decompression within 24 hours of insult is advocated to maximize the return of function. Despite previous literature showing poor neurological recovery with intervention after 24-72 hours, multiple cases have since shown noteworthy clinical improvement following significant delays in presentation. We report the case of a 55-year-old incarcerated male who presented to our hospital with a four-week history of a complete (American Spinal Injury Association (ASIA) A) SCI after a prison altercation. The patient exhibited profound deficits of over one-month duration, and magnetic resonance imaging (MRI) revealed an epidural abscess at T7-T8 with severe cord compression and another epidural abscess at L4-L5. This prompted immediate IV antibiotic therapy. A full neurological examination at hospital admission showed a complete absence of sensation, motor, rectal tone, and rectal function below T8, indicating a grade ASIA A SCI. Blood cultures grew Serratia marcescens. After thorough deliberation, considering over a month of complete neurological deficits, it was decided that surgical intervention would be unlikely to improve the patient's clinical status. Nonetheless, after only 24 hours of IV antibiotic administration, the patient progressed from an ASIA A to B, with a return of 100% accurate, although dull, sensation below T8. Within one week, his abscesses diminished on follow-up MRI, yet T7-T8 remained under significant pressure with no further clinical improvements. Due to his unexpected improvement to an ASIA B, which then plateaued at this level, surgery was again discussed in an attempt to maximize recovery. The patient wished to proceed, even given low chances of a meaningful recovery. He subsequently underwent evacuation and decompression. Two weeks postoperatively, the patient advanced from an ASIA B to C; he remained so until discharge 46 days after presentation and 30 days after surgical decompression. This case is noteworthy within the literature due to two compelling features. Firstly, it represents a significantly delayed presentation of a complete SCI with unexpected, meaningful, and swift improvement after medication and surgical intervention. Secondly, it is one of the few documented cases of Serratia marcescens spinal epidural abscess (SEA).

Fatal Cervical Spinal Epidural Abscess and Spondylodiscitis Complicated With Rhombencephalitis Caused by Klebsiella pneumoniae: A Case Report and Literature Review

Spinal epidural abscess (SEA) is a rare but sometimes life-threatening condition. The principal organisms in SEA and spondylodiscitis are gram-positive bacteria, e.g., Staphylococcus aureus and Streptococci. Spontaneous gram-negative SEA and spondylodiscitis especially Klebsiella pneumoniae are very rare. We report a 71-year-old Thai male with diabetes, presenting fever, enlarged neck mass, and progressive painful swallowing a week before admission. MRI of the whole spine demonstrated epidural abscess along the anterior thecal sac from C2 to C7 levels with spinal meningitis; multiple rim-enhancing lesions at the left sternocleidomastoid/levator scapulae, splenius capitis, semispinalis capitis, and bilateral scalene muscles; and rhombencephalitis with brain abscess. Klebsiella pneumoniae was isolated from blood culture. CT of the whole abdomen showed unremarkable intra-abdominal lesion. Intravenous ceftriaxone was administered, but the patient was unable to undergo surgical drainage due to unstable condition and died after two weeks of admission. Spontaneous SEA and spondylodiscitis caused by K. pneumoniae are very rare but sometimes fatal. In the case of SEA and spondylodiscitis, even when K. pneumoniae is uncommon, it should be also considered as a pathogen, especially when the patient had important risk factors.