Journal of Brain & Neuroscience Research Category: Clinical Type: Case Report
Spinal Epidural Abscess in Immunocompetent Child
- Al Saadi Tariq1, Al Shandoudi Leena2, Al Sharqi Jawahir3, Al Adawi Zakariya4, Al Sharqi Ali5*
- 1 Department Of Neurosurgery, Montreal Neurological Institute And Hospital, Khoula Hospital, McGill University, Montreal, Canada
- 2 Department Of Pediatrics, Sultan Qaboos University, Muscat, Oman
- 3 Department Of Pediatrics, Royal Hospital, Muscat, Oman
- 4 Department Of Pediatrics, Armed Force Hospital, Muscat, Oman
- 5 Department Of Neurosurgery, Sultan Qaboos University, Muscat, Oman
*Corresponding Author:
Al Sharqi AliDepartment Of Neurosurgery, Sultan Qaboos University, Muscat, Oman
Tel: +968 95262251,
Email: ali.sharqi95@gmail.com
Received Date: Nov 06, 2018 Accepted Date: Dec 14, 2018 Published Date: Dec 27, 2018
Abstract
Spinal Epidural Abscess (SEA) is uncommon and rare condition in immunocompetent population and even more rare in pediatric group. The incidence of spinal epidural abscess appears to be increasing and comprises up to 2 per 10,000 hospital admissions. The presentation is variable and diagnosis can be easily missed on first visit. The diagnosis is established by history, clinical examination finding, increased inflammatory markers and neurological imaging. Surgical decompression and drainage in combination with antibiotic for four to six weeks are the typical treatment for SEA. An alternative treatment with parenteral antibiotic only is an alternative treatment. We reported an 11-year-old girl presented fever, chest and back pain she was found to have unsteady gait and lower extremity weakness. Spinal MRI showed heterogeneous enhancing collection in the posterior epidural space from the level of T2 vertebra to T10 vertebra. She was treated with antibiotic for 6 weeks without complications.
Keywords
Abscess; Epidural; Immunocompetent; Pediatric; Spine
BACKGROUND
CASE REPORT
Her white blood cell 15,500/100ml3, absolute neutrophil count 10 and C-reactive protein 500mg/L. Urine analysis was unremarkable. Repeated blood cultures taken. Lumbar puncture was not performed as parent were totally refusing this test. She was started on IV ceftriaxone 2 grams twice daily and 1 gram daily. Whole spine-MRI was performed and showed heterogeneous enhancing collection in the posterior epidural space from the level of T2 vertebra to T10 vertebra (Figure 1). It measures 6mm in thickness causing compression and anterior displacement of the spinal cord with evidence of high signal at T9 and T10. Diffuse subcutaneous collection and edema noted in the posterior aspect of the lumbar spine.

Figure 1: Whole-spine T2-weighted magnetic resonance imaging with contrast extensive epidural collection extending from T2 to T10. Spinal cord is compressed anteriorly with normal signal.
During the period of admission, she was improving clinically and the inflammatory markers were decreasing. In the third day following antibiotics, her weakness started to improve. She retained back to her baseline by day eight. Following MRI after 3-weeks form initiation of treatment was done (Figure 2). She continued the same antibiotic for six weeks. She was discharge home clinically and vitally stable with follow up after 4 weeks in the clinic.

Figure 2: Whole-spine T1-weighted magnetic resonance imaging with contrast 3 weeks after parenteral antibiotic showing complete resolution of epidural abscess.
DISCUSSION
Including our report, we found a total of 24 pediatric SEA cases without predisposing factors, 12 were males and 12 were female, age range 16 days-17 years (Table 1). Most cases presented with fever and non-specific symptoms including neck and back pain, vomiting and irritability. Two cases were initially diagnosed with acute appendicitis. Lumbar puncture was done in 8 cases only, 1 case had normal LP results. In 8 cases, blood culture was done as part of patient initial workup. Staphylococcus aureus was the most common cause of SEA (n=14) [Methicillin-sensitive Staphylococcus aureus 45.8%, Methicillin-resistant Staphylococcus aureus 8.3%]. Surgical intervention was done in 14 cases; 11 had laminectomy and 3 drainage of the SEA. Ten cases received conservative management with antibiotics only. Seventy-nine percentage of cases received combination for more than one antibiotic agent based on culture and sensitivity. The average of therapy duration was 6 weeks. In four cases the duration was not specified.
Cases |
Gender, Age |
Spine Level |
Presentation |
Primary Diagnosis |
CSF |
Positive Blood Culture |
Etiology |
Fotaki [48] |
M, 2.5 y |
C3-T2 |
Fever, neck pain and stiffness |
Meningitis |
Pleocytosis, low glucose, elevated protein |
Yes |
Group A Streptococcus |
Horner [49] |
M, 34 d |
C3-C5 |
Fever, irritability, decreased oral intake |
Meningitis |
Pleocytosis (WBCs 2113/mm3) Low glucose, elevated protein |
Yes |
Methicillin-sensitive Staphylococcus aureus |
Paro-panjan [50] |
M, 3 wk |
C4-C5 |
Irritability, paresis and areflexia of both arms. |
- |
Pleocytosis |
No |
Group A Streptococcus |
Aycan [8] |
F, 13 y |
T12-L5 |
Fever, back pain, paraparesis, |
- |
Not performed |
Not available |
Methicillin- resistant Staphylococcus aureus |
Vergori [2] |
M, 15 y |
T11-L2 |
Fever, headache and back pain in lumbar-sacral region, bilateral leg weakness |
Meningitis |
Pleocytosis, glucose normal, protein elevated |
No |
Methicillin-sensitive Staphylococcus aureus |
Harris [3] |
M, 21 m |
L4-L5 |
Fever, refuse to walk |
Septic arthritis |
Not performed |
No |
Group A beta-hemolytic Streptococcus |
Hawkins [4] |
F, 17 y |
L1-L4 |
Fever, nausea, vomiting |
- |
Not performed |
No |
Unknown |
Hawkins [4] |
M, 3y |
T1-L2 |
Fever, stomachache |
- |
Not performed |
Yes |
Methicillin- resistant Staphylococcus aureus |
Hawkins [4] |
M, 1.2 y |
L3-L4 |
Refusal to walk, irritability, weakness |
- |
Not performed |
No |
Unknown |
Pathak [51] |
M, 13 y |
C7-T1 |
Transient fever, neck and upper back pain, tingling sensation in hands and feet, urine incontinence, abdominal distension, inability to sit and walk |
Acute myelitis, diskitis, meningitis |
800 cells/mmc, 2% PMN, glucose 21 mg/dl |
No |
Unknown |
Sales [52] |
M, 15 y |
L2-L3 |
Fever, urinary retention, Back pain, |
Low back pain and Not specified urinary retention |
Not performed |
Not available |
Staphylococcus aureus |
Hazelton [53] |
M, 16 d |
C3-C4 |
Fever, irritability |
- |
180 PMN, 9900 red blood cells |
Yes |
Methicillin-sensitive Staphylococcus aureus |
Mantadakis [46] |
F, 11 y |
T11-L4 |
Fever, lumbar pain |
Back pain |
Not performed |
No |
Methicillin-sensitive Staphylococcus aureus |
Rook [47] |
F, 15 y |
T3-T8 |
Right scapular pain, fever, chills with night sweats, headache, photophobia |
Right rhomboid muscle strain with spasm, acute febrile illness |
Normal |
Yes |
Methicillin-sensitive Staphylococcus aureus |
Tang [43] |
F, 7 wk |
T10-T12 |
Flaccid paraplegia |
Neoplasia |
Not performed |
Not available |
Staphylococcus aureus |
Kim [54] |
F, 10 y |
L3-L5 |
Fever, low back pain, radiating pain in both legs, saddle anesthesia, bladder and bowel dysfunction |
- |
Not performed |
Not available |
Staphylococcus aureus |
Shawar [55] |
F, 13 y |
Not available |
Fever, lumbar pain, headache, nausea, localized tenderness |
Viral infection |
WBCs>10,000/mm3, Undetectable glucose/protein |
Yes |
Methicillin-sensitive Staphylococcus aureus |
Raus [56] |
F, 3 m |
C5-C6 |
Neck stiffness, irritability, right upper extremity hypotonia, exaggerated tendon reflexes |
Meningoencephalitis |
Not available |
No |
Not available |
Bair-Meritt [42] |
F, 3 y |
L5-S1 |
Fever, malaise, right hip pain |
- |
Not performed |
Yes |
Oxacillin-sensitive Staphylococcus aureus |
Rood [57] |
M, 10 m |
L5-S1 |
Fever, back pain, gait change |
Bacterial infection of unknown location |
Not performed |
Not available |
Not available |
Prasad [58] |
F, 14 y |
Not available |
Abdominal tenderness |
Appendicitis |
Not performed |
Not available |
Not available |
Kiymaz [45] |
F, 10 y |
C2-C3 |
Fever, neck pain stiffness |
Meningitis |
Not performed |
No |
No microorganism isolated initially, 2 months later Streptococcus anginosus |
Flikweert [44] |
M, 7 y |
T3-T7 |
Fever, abdominal pain |
Appendicitis |
Not performed |
Not available |
Group A Streptococcus |
Our case |
F, 11 y |
T2-10 |
Fever, chest/back pain, LE weakness |
URTIs/Pneumonia/GBS |
Not performed |
Yes |
Methicillin-sensitive Staphylococcus aureus |
CONCLUSION
ACKNOWLEDGEMENT
FUNDING DISCLOSURE
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Citation: Tariq AS, Leena AS, Jawahir AS, Zakariya AA, Ali AS (2018) Spinal Epidural Abscess in Immunocompetent Child. J Brain Neursci 2: 005.
Copyright: © 2018 Al Saadi Tariq, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
