253
Clinical Neurology and Neurosurgery, 94 (1992) 253-255 0 1992 Elsevier Science Publishers
CLINEU
B.V. All rights reserved
0303-8467/92/S
05.00
00204
Case report
Iatrogenic acute spinal epidural abscess with septic meningitis: MR findings S. Shintani”, H. Tanakab, A. Irifune”, Y. Mitoh”, H. Udonod, A. Kanedad and T. Shiigai” Departments
of “Neurology, bAnesthesiology, ‘Dermatology, ‘Orthopedics, and “Internal Medicine, Toride Kyodo General Hospital,
Ibaraki, Japan (Received (Revised,
(Accepted
Key words:
Iatrogenic
disease;
Meningitis;
Epidural
22 January,
received
8 April,
abscess;
1992)
7 April,
1992)
1992)
Epidural
anaesthesia
Summary A contaminated septic meningitis.
catheter used in epidural anesthesia in a 71-year-old female produced acute epidural abscess and Methicillin-resistant Staphylococcus aureus (MRSA) was detected in a culture of the epidural pus.
Both T,-and Tz-weighted MR images showed low intensity mass lesion compressing the thecal sac behind the vertebral body L,. The low intensity lesion was probably pus with gas component. In these low intensity lesions in MR findings with gas component, MR was superior to myelography because it visualized both the degree of compression to the thecal sac and extension of the lesion in all directions.
Case report
sea, vomiting, fever, and somnolence. There were signs of meningeal irritation. Cranial nerves were intact. There
A previously healthy 71-year-old female had suffered from painful herpes zoster erythema located in a dermal L,-L, region in the left leg since October 6, 199 1. She was
was no paraparesis, but she had severe lumbago and percussion pain on L, and L, spinous processes. Therefore,
admitted to the department of dermatology on October 9. Epidural anesthesia was performed 2 days later by the anesthesiologist in order to reduce the neuralgia due to herpes zoster. A continuous epidural catheter was inserted from the L,/L, interlaminal space with a Tuohy needle, and the tip of the catheter was advanced 4 cm towards the cranium and located in the L, epidural space. From October 14 she developed severe headache, nau-
Correspondence to: Dr. S. Shintani, ride Kyodo Japan.
General
Hospital,
Tel.: 0297-74-5551;
Department
5901-l Terada,
Fax: 0297-74-2721.
of Neurology,
To-
Toride City, Ibaraki
302,
a diagnosis of meningitis and epidural infection, probably due to contamination of the epidural anesthesia catheter, was made. The catheter was immediately removed, and examined by bacterial and fungal cultures, Three days later methicillin-resistant Staphvlococcus aureus (MRSA) was detected in the culture. She was transferred from the department of dermatology to neurology on October 15, 1991. Laboratory examination revealed: 390 x 104/mm3 red blood cells (RBCs),
11.9
g/d1
hemoglobin,
34.9%
hematocrit,
18 300/ mm3 white blood cells (WBCs), 16.4 x 104/mm3 platelets. The white cell differential counts showed 93% neutrophils and 7% lymphocytes. Blood chemistry was normal including fasting blood sugar (114 mg/dl). Erythrocyte sedimentation rate (ESR) was 92 mm/h, and C-
254
Fig. 1. A: T,-weighted MR image (TR SOOITE 25) showing low intensity lesion behind the vertebral body L,. B: Tz-weighted MR image (TR 2OOOiTE110) showing also low intensity mass lesion compressing the thecal sac in the L, epidural space.
reactive
protein
(CRP)
was 29.19 mgidl (normal co.30
mgidl). Examination of cerebrospinal fluid (CSF) obtained at LJLs puncture contained 116 1 leukocytes/mm~, 94% polymorphonuclear cells, 6% lymphocytes, 1030 mgidl total protein content, 52 mgidl glucose, with 238 mg/dl plasma glucose. Gram stain, India ink preparations, and routine bacterial and fungal cultures of the CSF were negative. CSF smears were negative for acid-fast bacilli (AFB). Polymerase chain reaction (PCR) for rapid diagnosis of tuberculous meningitis was negative. The herpes zoster in CSF-herpes zoster antibody titer was increased 16 times by complement fixation (CF) method. Chest X-ray films were normal. Therapy was started with imipenem 2 g/day, arbekacin 200 mgiday, and acyclovir 1000 mgiday. On October 17, the T,- and T,-weighted MR images showed low intensity lesions in the L, epidural space, suggesting an epidural abscess (Fig. 1). The next day, L, laminectomy including L, lower portion and L, upper portion revealed massive pus of yellow-green color located in the epidural space which was removed. The dura was thickened and yellow in color. After the laminectomy and removal of the abscess, the patient became afebrile and alert, and the lumbago and headaches disappeared. Serial examination
of CSF then improved remarkably (Table 1). On November 15, 199 1, the CSF became finally normal except for mildly increased protein. and antibiotics were discontinued.
Discussion ~pidural abscess is a rare cause of back pain [l-3]. When these abscesses are not diagnosed and remain untreated, the neurological deficit usually remains permanent. Spinal epidural abscesses may be caused by a variety of pyogenic bacteria, especially Staphylococcus aureus, as well as ~yc~~~cter~u~? tu~er~~lo~~~,fungi, and occasionally helminths [2]. The two most important routes by which microorganisms can reach the epidural space are hematogenous dissemination from a distant infection or direct extension from a contiguous site [I .2]. Direct inoculation of organisms into the paraspinal region as a complication of trauma, surgery, lumbar puncture, or epidural anesthesia represents a third but less common mechanism for the development of vertebral osteomyelitis and/or epidural abscess [4,5], The case presented above is an eloquent example of this.
255 TABLE 1 CEREBROSPINAL
FLUID ANALYSIS
Lumbar CSF was obtained by L,, interlaminal obtained by C,,2 lateral puncture. Hospital Specimen day
Leukocytes (No./ mm3)
Neutrophils (%)
puncture avoiding the epidural abscess in L, epidural space. Cervical CSF was
MonoProtein nuclear (mgidl) cells (%)
Glucose Simulta- Color (mg/dl) neous blood glucose
I
Lumbar CSF
1161 1
94%
6%
10301
52
238
13
LJ Cervical CSF
361 1
4%
96%
1501
72
194
23
(C,,,) Cervical CSF
251
1%
99%
1541
102
38
(C/Z) Cervical CSF
10
3%
97%
46
14
178
Xanthochromia Xanthochromia watery clear
-
watery clear
Culture
Antibody titer (CF) in herpes zoster
negative
16 times
negative
twice
negative
once
negative
below once
(C,,,) “CF=complement
The patient
fixation method (normal, below once).
was previously
healthy
and had no diabe-
tes mellitus. Immunological study showed no abnormalities, and she had not been treated with immunosuppressive agents. Laboratory findings, such as leukocytosis (WBCs 18 300/mm3), elevated ESR (92 mm/h), and CRP (29.19 mg/dl), showed acute severe inflammation. Methicillin-resistant Staphylococcus aureus (MSRA) was detected in epidural pus culture. Because the MRSA was resistant to penicillinase-resistant penicillin or third-generation cephalosporin, surgical intervention was necessary followed by treatment with imipenem and arbekacin.
NMR is the most reliable non-invasive study in patients with suspected epidural abscesses [6-81. In our case, both T,- and T,-weighted MR images revealed low intensity mass lesion compressing the thecal sac behind the vertebral body L, (Fig. lA,B). The low intensity lesion was probably pus with air collection, because the presence of fluid produces high intensity on T,-weighted MR images [9]. Myelography has been the procedure of choice for evaluation of the vertebral canal for many years. But, in a low intensity lesion with gas component in MR finding, our case showed that NMR is superior to myelography because it visualized both the degree of compression to the thecal sac and extension of the lesion in all directions. However, when the epidural abscess contains no gas component, NMR diagnosis is difficult, as neither T,nor T,-weighted images allow one to distinguish pus
from CSF. In that case, the myelogram NMR.
is superior to
References Baker, A.S., Ojemann, R.G., Swartz, M.N. and Richardson, E.P., Jr. (1975) Spinal epidural abscess. N. Engl. J. Med., 293: 463468. Verner, E.F. and Musher, D.M. (1985) Spinal epidural abscess. Med. Clin. North Am., 69: 375-384. O’Sullivan, R., Mckenzie, A. and Hennessy, 0. (1988) Epidural and paraspinal inflammatory conditions. Aust. Radiol., 32: 203-206. Schumtzhard, E., Aichner, F., Dierck, R.A. et al. (1986) New perspectives in acute spinal epidural abscess. Neurochirurgica, 80: 105-108. Bergman, I., Wald, E.R., Meyer, J.D. and Painter, M.J. (1983) Epidural abscess and vertebral osteomyelitis following serial lumbar punctures. Pediatrics, 72: 476480. Erntell, M., Holtas, S., Norlin, K., Dahlquist, E. and Nilsson-Ehle, I. (1988) Magnetic resonance imaging in the diagnosis of spinal epidural abscess. Stand. J. Infect. Dis., 20: 323-321. Bertino, R.E., Porter, B.A., Stimac, G.K. and Tepper, S.J. (1988) Imaging spinal osteomyelitis and epidural abscess with short T, inversion recovery (STIR). AJNR, 9: 563-564. Post, M.J.D., Quencer, R.M., Montalvo, B.M., Katz, B.H., Eismont, F.J. and Green, B.A. (1988) Spinal infection: evaluation with MR imaging and intraoperative US. Radiology, 169: 765-771. Kirzner, H., Oh, Y.K. and Lee, S.H. (1988) Intraspinal air: a CT finding of epidural abscess. AJNR, 151: 1217-1218.
Clinical Neurology and Neurosurgery, 94 (1992) 253-255 0 1992 Elsevier Science Publishers
CLINEU
B.V. All rights reserved
0303-8467/92/S
05.00
00204
Case report
Iatrogenic acute spinal epidural abscess with septic meningitis: MR findings S. Shintani”, H. Tanakab, A. Irifune”, Y. Mitoh”, H. Udonod, A. Kanedad and T. Shiigai” Departments
of “Neurology, bAnesthesiology, ‘Dermatology, ‘Orthopedics, and “Internal Medicine, Toride Kyodo General Hospital,
Ibaraki, Japan (Received (Revised,
(Accepted
Key words:
Iatrogenic
disease;
Meningitis;
Epidural
22 January,
received
8 April,
abscess;
1992)
7 April,
1992)
1992)
Epidural
anaesthesia
Summary A contaminated septic meningitis.
catheter used in epidural anesthesia in a 71-year-old female produced acute epidural abscess and Methicillin-resistant Staphylococcus aureus (MRSA) was detected in a culture of the epidural pus.
Both T,-and Tz-weighted MR images showed low intensity mass lesion compressing the thecal sac behind the vertebral body L,. The low intensity lesion was probably pus with gas component. In these low intensity lesions in MR findings with gas component, MR was superior to myelography because it visualized both the degree of compression to the thecal sac and extension of the lesion in all directions.
Case report
sea, vomiting, fever, and somnolence. There were signs of meningeal irritation. Cranial nerves were intact. There
A previously healthy 71-year-old female had suffered from painful herpes zoster erythema located in a dermal L,-L, region in the left leg since October 6, 199 1. She was
was no paraparesis, but she had severe lumbago and percussion pain on L, and L, spinous processes. Therefore,
admitted to the department of dermatology on October 9. Epidural anesthesia was performed 2 days later by the anesthesiologist in order to reduce the neuralgia due to herpes zoster. A continuous epidural catheter was inserted from the L,/L, interlaminal space with a Tuohy needle, and the tip of the catheter was advanced 4 cm towards the cranium and located in the L, epidural space. From October 14 she developed severe headache, nau-
Correspondence to: Dr. S. Shintani, ride Kyodo Japan.
General
Hospital,
Tel.: 0297-74-5551;
Department
5901-l Terada,
Fax: 0297-74-2721.
of Neurology,
To-
Toride City, Ibaraki
302,
a diagnosis of meningitis and epidural infection, probably due to contamination of the epidural anesthesia catheter, was made. The catheter was immediately removed, and examined by bacterial and fungal cultures, Three days later methicillin-resistant Staphvlococcus aureus (MRSA) was detected in the culture. She was transferred from the department of dermatology to neurology on October 15, 1991. Laboratory examination revealed: 390 x 104/mm3 red blood cells (RBCs),
11.9
g/d1
hemoglobin,
34.9%
hematocrit,
18 300/ mm3 white blood cells (WBCs), 16.4 x 104/mm3 platelets. The white cell differential counts showed 93% neutrophils and 7% lymphocytes. Blood chemistry was normal including fasting blood sugar (114 mg/dl). Erythrocyte sedimentation rate (ESR) was 92 mm/h, and C-
254
Fig. 1. A: T,-weighted MR image (TR SOOITE 25) showing low intensity lesion behind the vertebral body L,. B: Tz-weighted MR image (TR 2OOOiTE110) showing also low intensity mass lesion compressing the thecal sac in the L, epidural space.
reactive
protein
(CRP)
was 29.19 mgidl (normal co.30
mgidl). Examination of cerebrospinal fluid (CSF) obtained at LJLs puncture contained 116 1 leukocytes/mm~, 94% polymorphonuclear cells, 6% lymphocytes, 1030 mgidl total protein content, 52 mgidl glucose, with 238 mg/dl plasma glucose. Gram stain, India ink preparations, and routine bacterial and fungal cultures of the CSF were negative. CSF smears were negative for acid-fast bacilli (AFB). Polymerase chain reaction (PCR) for rapid diagnosis of tuberculous meningitis was negative. The herpes zoster in CSF-herpes zoster antibody titer was increased 16 times by complement fixation (CF) method. Chest X-ray films were normal. Therapy was started with imipenem 2 g/day, arbekacin 200 mgiday, and acyclovir 1000 mgiday. On October 17, the T,- and T,-weighted MR images showed low intensity lesions in the L, epidural space, suggesting an epidural abscess (Fig. 1). The next day, L, laminectomy including L, lower portion and L, upper portion revealed massive pus of yellow-green color located in the epidural space which was removed. The dura was thickened and yellow in color. After the laminectomy and removal of the abscess, the patient became afebrile and alert, and the lumbago and headaches disappeared. Serial examination
of CSF then improved remarkably (Table 1). On November 15, 199 1, the CSF became finally normal except for mildly increased protein. and antibiotics were discontinued.
Discussion ~pidural abscess is a rare cause of back pain [l-3]. When these abscesses are not diagnosed and remain untreated, the neurological deficit usually remains permanent. Spinal epidural abscesses may be caused by a variety of pyogenic bacteria, especially Staphylococcus aureus, as well as ~yc~~~cter~u~? tu~er~~lo~~~,fungi, and occasionally helminths [2]. The two most important routes by which microorganisms can reach the epidural space are hematogenous dissemination from a distant infection or direct extension from a contiguous site [I .2]. Direct inoculation of organisms into the paraspinal region as a complication of trauma, surgery, lumbar puncture, or epidural anesthesia represents a third but less common mechanism for the development of vertebral osteomyelitis and/or epidural abscess [4,5], The case presented above is an eloquent example of this.
255 TABLE 1 CEREBROSPINAL
FLUID ANALYSIS
Lumbar CSF was obtained by L,, interlaminal obtained by C,,2 lateral puncture. Hospital Specimen day
Leukocytes (No./ mm3)
Neutrophils (%)
puncture avoiding the epidural abscess in L, epidural space. Cervical CSF was
MonoProtein nuclear (mgidl) cells (%)
Glucose Simulta- Color (mg/dl) neous blood glucose
I
Lumbar CSF
1161 1
94%
6%
10301
52
238
13
LJ Cervical CSF
361 1
4%
96%
1501
72
194
23
(C,,,) Cervical CSF
251
1%
99%
1541
102
38
(C/Z) Cervical CSF
10
3%
97%
46
14
178
Xanthochromia Xanthochromia watery clear
-
watery clear
Culture
Antibody titer (CF) in herpes zoster
negative
16 times
negative
twice
negative
once
negative
below once
(C,,,) “CF=complement
The patient
fixation method (normal, below once).
was previously
healthy
and had no diabe-
tes mellitus. Immunological study showed no abnormalities, and she had not been treated with immunosuppressive agents. Laboratory findings, such as leukocytosis (WBCs 18 300/mm3), elevated ESR (92 mm/h), and CRP (29.19 mg/dl), showed acute severe inflammation. Methicillin-resistant Staphylococcus aureus (MSRA) was detected in epidural pus culture. Because the MRSA was resistant to penicillinase-resistant penicillin or third-generation cephalosporin, surgical intervention was necessary followed by treatment with imipenem and arbekacin.
NMR is the most reliable non-invasive study in patients with suspected epidural abscesses [6-81. In our case, both T,- and T,-weighted MR images revealed low intensity mass lesion compressing the thecal sac behind the vertebral body L, (Fig. lA,B). The low intensity lesion was probably pus with air collection, because the presence of fluid produces high intensity on T,-weighted MR images [9]. Myelography has been the procedure of choice for evaluation of the vertebral canal for many years. But, in a low intensity lesion with gas component in MR finding, our case showed that NMR is superior to myelography because it visualized both the degree of compression to the thecal sac and extension of the lesion in all directions. However, when the epidural abscess contains no gas component, NMR diagnosis is difficult, as neither T,nor T,-weighted images allow one to distinguish pus
from CSF. In that case, the myelogram NMR.
is superior to
References Baker, A.S., Ojemann, R.G., Swartz, M.N. and Richardson, E.P., Jr. (1975) Spinal epidural abscess. N. Engl. J. Med., 293: 463468. Verner, E.F. and Musher, D.M. (1985) Spinal epidural abscess. Med. Clin. North Am., 69: 375-384. O’Sullivan, R., Mckenzie, A. and Hennessy, 0. (1988) Epidural and paraspinal inflammatory conditions. Aust. Radiol., 32: 203-206. Schumtzhard, E., Aichner, F., Dierck, R.A. et al. (1986) New perspectives in acute spinal epidural abscess. Neurochirurgica, 80: 105-108. Bergman, I., Wald, E.R., Meyer, J.D. and Painter, M.J. (1983) Epidural abscess and vertebral osteomyelitis following serial lumbar punctures. Pediatrics, 72: 476480. Erntell, M., Holtas, S., Norlin, K., Dahlquist, E. and Nilsson-Ehle, I. (1988) Magnetic resonance imaging in the diagnosis of spinal epidural abscess. Stand. J. Infect. Dis., 20: 323-321. Bertino, R.E., Porter, B.A., Stimac, G.K. and Tepper, S.J. (1988) Imaging spinal osteomyelitis and epidural abscess with short T, inversion recovery (STIR). AJNR, 9: 563-564. Post, M.J.D., Quencer, R.M., Montalvo, B.M., Katz, B.H., Eismont, F.J. and Green, B.A. (1988) Spinal infection: evaluation with MR imaging and intraoperative US. Radiology, 169: 765-771. Kirzner, H., Oh, Y.K. and Lee, S.H. (1988) Intraspinal air: a CT finding of epidural abscess. AJNR, 151: 1217-1218.
