FACETS OF SPINAL EPIDURAL ABSCESS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Spinal epidural abscess (SEA) is a rare but serious CNS infection. The classic diagnostic triad consists of spinal pain, fever, and neurologic deficits, however, some or even all of these are often absent. CASE PRESENTATION: An 88-year-old woman with a past medical history of polycythemia vera with chronic leukocytosis and chronic kidney disease (CKD) presented with progressive back pain. An acute rise in white blood cell (WBC) count above her baseline to 37.24 K/uL was noted. She underwent facet joint articular steroid injections of L3-S1. Five days later, the patient presented again with worsening lumbar back pain. She was afebrile and hemodynamically stable. No sensory level loss or bladder/bowel incontinence were noted. WBC count was 24 K/uL. On day three, she became hypotensive. WBC count was now 30.64 K/uL and lactate was 7.9 mmol/L. Blood cultures were drawn. A CT of the chest/abdomen/pelvis and lumbar spine without contrast did not reveal an infectious source. The patient empirically received broad spectrum antibiotics and IV fluids and was stabilized in the intensive care unit. On day eight, she underwent a full spine MRI with gadolinium for continued back pain, revealing an extensive epidural abscess from T7 to T12, compressing the spinal cord, as well as discitis at T12-L1 and L1-L2. C-reactive protein was 92.91 mg/L and erythrocyte sedimentation rate was 40 mm/hr. The patient underwent T6-L5 laminectomies, abscess evacuation, and T9-S1 fusion. Intra-operative cultures and 3 sets of blood cultures were negative and she was transitioned to ceftazidime and vancomycin for a 42-day course. On day 22, following a suspected aspiration event, the patient experienced acute hypoxia, fever, and hypotension, and subsequent PEA arrest. Cardiopulmonary resuscitation was discontinued per the family’s request and the patient expired. DISCUSSION: This patient developed a SEA, likely as a complication of facet joint injection. MRI with gadolinium is the diagnostic modality of choice and empiric broad spectrum antibiotics are recommended. However, diagnosis is often delayed, because patients commonly present without classic findings, as with our patient. Indeed, fever may be absent in up to 48% of cases. In addition, her history of polycythemia vera made it difficult to assess the significance of her leukocytosis. A decision guideline, as previously implemented in an experimental fashion in 2011 by Davis et al., may have expedited her diagnosis. This guideline risk-stratified patients based on the presence of risk factors and elevation in inflammatory markers and would have resulted in the recommendation of spinal imaging in this patient with recent spinal procedure and CKD (both considered risk factors). CONCLUSIONS: The diagnosis of SEA is often delayed due to lack of classic findings. Therefore, it is crucial to assess the need for spinal imaging in patients without apparent cause of sepsis. Reference #1: Davis DP, Salazar A, Chan TC, et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine. 2011;14(6):765. Reference #2: Davis DP, Wold RM, Patel RJ, et al. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med. 2004;26(3):285. Reference #3: Curry WT Jr, Hoh BL, Amin-Hanjani S, et al. Spinal epidural abscess: clinical presentation, management, and outcome. Surg Neurol. 2005;63(4):364. DISCLOSURES: No relevant relationships by Mouhanned Eliliwi, source=Web Response No relevant relationships by Jennifer Meyfeldt, source=Web Response No relevant relationships by Daniel Wang, source=Web Response