Neurol Sci DOI 10.1007/s10072-014-1670-3
LETTER TO THE EDITOR
Spinal epidural abscess as a complication of cardiosurgery Federico Pacei • Luciano Bet
Received: 4 November 2013 / Accepted: 30 January 2014 Ó Springer-Verlag Italia 2014
We present the case of a 77-year-old man, suffering from essential hypertension, dyslipidemia, obesity, atrial fibrillation treated with oral anticoagulation and with a previous PM implantation for brady-arrhythmias. The patient was also affected by steatosis liver disease, cholelithiasis, nephrolithiasis, chronic idiopathic thrombocytopenia, hypothyroidism, obstructive sleep apnea syndrome and chronic muscle pain caused by statins. Two months before, the patient underwent surgery for aortic valve replacement with a mechanical prosthesis due to aortic valve stenosis. One month after the first surgery, the patient was re-hospitalized, due to a bacterial endocarditis on the mechanic aortic valve and, therefore, underwent surgery for the replacement of the aortic valve with a new mechanical prosthesis and myocardial revascularization by CABG. About a week after discharge following the second heart surgery, the patient came to the Emergency Department of our Hospital, after the sudden onset of pain to the neck, which gradually worsened, radiated to the upper and lower limbs and was accompanied by severe numbness and weakness in all four limbs, until he became quadriplegic in few minutes. Given the acute onset of the symptoms, the hypothesis was of an infarct of the spinal cord and the patient was admitted to the Stroke Unit. The blood chemistry showed: iron deficiency anemia, 46.000/ll platelets, which represented a preexisting chronic idiopathic F. Pacei (&) IRCCS Policlinico San Donato, P.za Malan 1, San Donato Milanese, 20097 Milan, Italy e-mail: [email protected]
L. Bet Department of Biomedical Sciences for Health, University of Milan, Milan, Italy e-mail: [email protected]
thrombocytopenia. C reactive protein was normal, CEA, CA-15.3, NSE, CA-19.9 were normal, but CA-125 was 88.6 lg/ml (\21.0 lg/ml). E. K. G. showed atrial fibrillation superimposed the rhythm induced by PM. The echocardiogram showed a correct functioning of the mechanical prosthesis. No images related to vegetation or other abnormalities in the valvular prosthesis. The neurological examination, performed in the Stroke Unit showed neck pain, generalized hyporeflexia without asymmetry. The weakness had almost completely resolved. A brain and cervical spine MRI was performed (Fig. 1). The patient had a PM and, therefore, it had to be temporarily turned off during the MRI examination. This was performed under the supervision of the arrhythmology team. After this exam, the patient was screened for myocardial infarction markers, which always resulted normal. MRI was performed using FLAIR, T2 and T1-weighted imaging before and after administration of paramagnetic contrast (Gd-BOPTA, 0.075 mmol/kg), and diffusionweighted sequences. Neuroimaging showed meningeal thickening along the right hemispheric convexity, dural thickening and nodular posterolateral right at C6–C7 with contrast enhancement, which resulted in a corresponding compression of the medulla. In the section of the spinal cord between C4 and T1, signal alteration was noted as a hyperintensity on T2-weighted images. This change was due to compressive myelopathy. Initially, the suspect was of a neoplastic lesion and the patient underwent neurosurgical evaluation  that excluded the possibility of surgical intervention. An oncologist also excluded a neoplastic origin. Thus, it was hypothesized that the intra-canal extramedullary mass was derived from an infectious pathogenesis, given the temporal correlation with bacterial endocarditis. We prefer not to perform the CSF analysis,
Fig. 1 T2-weighted images show dural thickening and nodular posterolateral right at C6–C7
Fig. 2 T2-weighted images showing an almost complete regression of the abscess
considering the risk–benefit ratio, as the patient was affected by thrombocytopenia and was also taking oral anticoagulant for the mechanical prosthesis. Antibiotic therapy was started based on the antibiogram of the infective endocarditis. The causative agent was found to be Staphylococcus Lugdunensis and the most appropriate antibiotic was found to be linezolid, so it was administered intravenously at 600 mg/day. After 8 days of therapy, an MRI of the brain and cervical (Fig. 2) spine was performed with the same sequences of the previous which showed an almost complete regression of the abscess. As a probable toxic effect of the antibiotic, in the 10th day of therapy, there was a worsening of thrombocytopenia with a nadir of 13.000/ll. So linezolid was stopped and was replaced with IV administration of Vancomycin 2 gr/24 h for two more weeks, and subsequently started antibiotic therapy orally with 800 mg sulfamethoxazole, trimethoprim 160 mg for 15 days.
During the hospitalization, the clinical condition remained stable. The patient has worn for the first 2 weeks a cervical collar to prevent sudden movements of the spine and during this period remained bedridden. In the following, the patient has been practiced physiotherapy with the early restoration of deambulation. After 3 months, patient underwent a new MRI (Fig. 3) with the same sequences as the previous two, in which demonstrated the complete resolution of the epidural spinal abscess. Spinal Epidural Abscess is a rare but serious pathological condition, featuring a multiple etiopathogenesis, to which it is fundamental to pay attention, since patients affected can be subjected to disastrous consequences [2–4]. It represents a diagnostic challenge , since it is often confused with other diseases or remains undiagnosed. Early recognition and treatment is therefore essential to prevent or minimize spinal lesions and subsequent permanent neurological deficits.
Fig. 3 T2-weighted images showing a complete regression of the abscess
Of this case report we want to emphasize in particular the emboli source as a rare cause of spinal epidural abscess. We also want to point out the particular conditions under which the patient underwent MRI. We want to thank the ‘‘Polli-Stoppani’’ foundation for its support.
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