Spinal epidural abscess secondary to gram-negative bacteria: case report and literature review

Abstract

Bacterial spinal epidural abscess (SEA) is a rare suppurative infection that commonly presents with nonspecific symptoms along with the infrequent triad of fever, back pain, and neurological deficits. Risk factors include diabetes mellitus, intravenous drug use, degenerative disc disease, infection with human immunodeficiency virus, and recent trauma or surgery. Patients with SEA often experience poor outcomes such as permanent neurological deficits, residual motor weakness, and even death. Staphylococcus aureus is the most predominant organism known to cause SEA; however, gram-negative bacteria are isolated in a small percentage of cases. Here we report three cases of SEA caused by gram-negative organisms. Each patient had identifiable risk factors known to increase the risk for SEA, and upon presentation had symptoms of SEA. Upon work up, the patients had positive cultures for gram-negative organisms and MRI imaging confirmed the presence of SEA. One patient made a full recovery while the other two cases resulted in permanent paraplegia. These cases stress the importance of considering SEA even in the presence of gram-negative infections, despite them being a rare cause. Furthermore, these cases emphasize the importance of broad-spectrum antibiotics that cover gram-negative bacteria in patients found to have risk factors along with symptoms of SEA.

<p>Studies on 11 Cases of Spinal Epidural Abscess and Literature Review</p>

“…Spinal MRI is the first choice for the diagnosis of SEA. 6,15 When the patient has back pain, neurological deficits or fever symptoms, and hematological examination shows elevated levels of CRP and ESR, early spinal MRI should be performed as soon as possible. Early identification of SEA can avoid serious complications.…”

“…Pathogenic bacteria can enter the epidural space through continuous diffusion or blood-borne diffusion. 6 Previous study has shown that several conditions, such as diabetes, intravenous drug abuse, human immunodeficiency virus (HIV) infection, spinal degenerative diseases, recent spinal trauma or surgery, and epidural injection of drugs, are risk factors for SEA. 7 The incidence of SEA is estimated to be 1.2-8/10,000.…”

Spinal epidural empyema in a colobus monkey

“…4 In humans with SEE, the bacteria gain access to the epidural space via haematogenous spread or direct access to the vertebral canal. 4,6,7 Risk factors include immunocompromised states such as diabetes mellitus or chronic kidney failure, bacteremia, intra-venous drug use, or through procedures involving the vertebral canal such as epidurals or central nervous system surgery. 6,7 In humans, symptoms start with fever and back pain and can progress to neurologic deficits, paraplegia, sepsis and death.…”

“…4,6,7 Risk factors include immunocompromised states such as diabetes mellitus or chronic kidney failure, bacteremia, intra-venous drug use, or through procedures involving the vertebral canal such as epidurals or central nervous system surgery. 6,7 In humans, symptoms start with fever and back pain and can progress to neurologic deficits, paraplegia, sepsis and death. The majority of human SEEs are caused by S. aureus, but can also be seen with gram-negative bacteria such as E. coli and Enterobacter species.…”

Brucellosis Spinal Epidural Abscess: A Case Series of Fourteen Patients

“…Most reports in the literature are diagnosed by brucella serology [12,25,26]. Magnetic resonance imaging (MRI) is the gold standard for diagnosis of SEA [15,27,28]. X-ray and CT are convenient and quick, and can better show the condition of bone involvement, but the diagnosis of SEA is not as good as MRI.…”