Diffusion-Weighted MR Imaging of Intramedullary Spinal Cord Abscess: Fig 1.

Abstract

SUMMARY:Early diagnosis and prompt initiation of adequate treatment are essential for clinical outcome in ISCA. We report a case in which DWI provided a more specific diagnosis than conventional MR imaging and allowed differentiation of a ring-enhancing lesion from intramedullary tumor. Diagnosis was proved by PCR from CSF (Streptococcus intermedius). Adequate antibiotic treatment was immediately initiated, and the patient recovered completely.ABBREVIATIONS: ADC ϭ apparent diffusion coefficient; DWI ϭ diffusion-weighted imaging; Gd ϭ gadolinium; ISCA ϭ intramedullary spinal cord abscess; PCR ϭ polymerase chain reaction I SCA is a rare entity that was first described by Hart in 1830, 1 and until now, to our knowledge, Ͻ100 cases have been reported in the literature. The early clinical suspicion and radiologic diagnosis are mandatory to start appropriate medical or surgical treatment and to avoid irreversible spinal cord damage. The radiologic technique of first choice is unambiguously MR imaging with intravenous Gd-chelates application, but differentiation from intramedullary tumors may be difficult. Case ReportA 80-year-old female patient with diabetes mellitus had been admitted with thoracic back pain after a collapse 2 days before. Other complaints were weakness in both legs, headache, and urinary incontinence.The clinical examination revealed slightly elevated body temperature (37.8°C), local tenderness along the thoracic spine, monoparesis, and hypoesthesia of the left leg below the T7 level and a positive Babinski sign on the left side. Blood tests at admission showed the following values: increased leukocytes of 16,700/L, an erythrocyte sedimentation rate of 16 mm/h, and moderately elevated C-reactive protein (69.5 mg/L). Findings of repeated blood and urine cultures were negative.Unremarkable conventional radiographs of the thoracic spine were followed by conventional MR imaging (including intravenous Gd-chelates application), which did not show any signs of contusion or fracture in the thoracic vertical bodies but did show an edema of the spinal cord extending from level T4 to T12 and a focal ring-enhancing lesion on level T8 with central necrosis and a diameter of 2 cm ( Fig 1A, -B). On T2-weighted images, the hypointense rim of the lesion could be delineated (Fig 1B). To differentiate an abscess from a tumor, we performed additional DWI with an axial and sagittal single-shot echo-planar spin-echo sequence. The images were acquired with b-values of 0 and 1000 s/mm 2 . The cavity of the lesion appeared strongly hyperintense on DWI and showed low ADCs on the ADC map compared with the myelon above and below the lesion, suggesting an intraspinal abscess (Fig 1C, -D). Lumbar puncture yielded the following values: white blood cells, 466/L; protein, 800 mg/L; and lactate, 4.7 mmol/L. CSF microscopy found predominantly polynuclear white blood cells but no tumor cells. Results of CSF Gram stain and culture were negative. PCR from CSF yielded deoxyribonucleic acid of Streptococcus intermedius. Therapy was initiat...

Cervical Spinal Cord Intramedullary Abscess: Streptococcus intermedius

“…4 In this case, the most likely etiology was suspected to be hematogenous spread of infective foci from the lung. Reported cases of hematogenous seeding of infection to the spinal cord have been documented in the past, often affecting the following groups of patients: Intravenous drug users, diabetics, or the immunosuppressed.…”

“…Previous case reports depict patients presenting acutely with symptoms of weakness, neck and/or back pain, reduced sensation, urinary retention, and fever. 4,[10][11][12] Inflammatory markers, such as white cell count (WCC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were abnormally high in some cases. 4,11,12 but within normal parameters in others.…”

“…4,[10][11][12] Inflammatory markers, such as white cell count (WCC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were abnormally high in some cases. 4,11,12 but within normal parameters in others. 10 The differential diagnosis for such a constellation of symptoms is varied, making early diagnosis difficult.…”

“…2 There are four other reported cases of IASC caused by S. milleri, with S. intermedius responsible for infection in at least two of the aforementioned cases. [4][5][6][7] Previous literature also shows that S. intermedius has been found to be a typical causative agent in CNS abscesses. 8,9 The virulence of S. intermedius suggests that it should be considered in clinical scenarios of neurological impairment involving infection of the medullary spinal cord.…”

Intramedullary abscess complicating congenital dermal sinus tract in an infant: A rare occurrence

“…The radiological findings may be difficult to differentiate from an intramedullary tumour as with our patient. Diffusion-weighted imaging (DWI) has been recommended as a more sensitive and specific method for differentiating intra-spinal abscesses from cystic or necrotic tumours 7,8 .…”