Acute Epidural Abscess Complicating Pneumococcal Meningitis in Adult

Khalid Abidi, MD; Fatima Zohra Ahouzi, MD; Rachid Gana, MD; Tarek Dendane, MD; Naoufel Madani, MD; Amine Ali Zeggwagh, MD; Redouane Abouqal, MD


South Med J. 2011;104(1):64-67. 

In This Article

Case Report

A 35-year-old man without past medical history presented 48 hours before admission with a fever, headache, vomiting, and altered mental status. Upon admission to our medical intensive care unit, the patient was agitated and confused. The Glasgow coma scale score was 10/15, blood pressure 150/80 mm Hg, pulse rate 106 beats/min, respiratory rate 18 beats/min, and temperature 38.7°C. Neurologic examination revealed neck stiffness, but pupils were equal and reactive, and sensorimotor examination and deep tendon reflexes were normal. The patient walked and was able to move his lower extremities. A contrast computed tomography (CT) scan of the brain showed an empyema in the left pontocerebellar flexure with thrombosis of the right cavernous sinus. An initial lumbar puncture revealed 1,000 cells/mm3 (96% polymorphonuclear cells and 4% lymphocytes), the protein level was 300 mg/dL, and the cerebrospinal fluid (CSF) glucose level was less than 20% of the serum glucose level. Gram-positive diplococci were present in the CSF, and the culture was positive for Streptococcus pneumoniae. The culture antibiogram was not available. Laboratory examination demonstrated a leukocyte count of 25,200 cells/mm3 (85% neutrophils). Serum C-reactive protein concentration was 9 mg/dL. Ear examination revealed stinking otorrhea with presence of tissue filling in the external auditory canal. CT of the petrous bone showed posterior lysis. Intravenous parenteral antibiotics were started with ceftriaxone 75 mg/kg/24 h (3 g twice daily) and metronidazole 500 mg thrice daily. The patient was given intravenous sodic heparin (500 IU/kg/24 h) for treatment of cerebral thrombosis. The evolution was marked by persistence of fever, meningeal syndrome, and altered mental status. On the sixth day of hospitalization, a second lumbar puncture showed a purulent fluid made of 2,000 cells/mm3 (98% polymorphonuclear cells and 2% lymphocytes), the protein level was 300 mg/dL, and the CSF glucose level was less than 10% of the serum glucose level. There were no findings on Gram stain of CSF, and cultures of blood and CSF were sterile. However, continuous intravenous vancomycin was added (50 mg/kg/24 h) to the other antimicrobial agents. There was improvement of the fever and mental status. On the eighth day of hospitalization, neurologic examination revealed a modified Frankel grade C with monoplegia of the right lower limb and monoparesis of the left lower limb, a saddle anesthesia, and urinary retention; deep tendon reflexes were normal in the upper extremities but absent in lower extremities.[8] These findings suggest involvement of cauda equina syndrome. Magnetic resonance imaging (MRI) of the spine with gadolinium-diethylenetriamine penta-acetic acid (Gd-DTPA) revealed intense enhancement of the cauda equina and lumbosacral nerve roots, with a suppurated collection at L2-L3 and other small collections at the level of T4-T9 (Fig. 1, A and B). We consulted a surgeon for further therapy, and surgical decompression by laminectomy was performed. The culture of epidural lumbar abscess revealed no growth of any organism. Antibiotherapy was followed for eight weeks with oral anticoagulants: acenocoumarol 20 mg twice daily. On the 68th day of hospitalization, at the end of the antibiotic treatment, MRI showed a clear regression of the lesions comparative to the data of the previous MRI, but without clinical improvement (Fig. 2, A and B). The patient's symptoms improved over the next eight months. He began to move his lower extremities. He could walk with support, with flaccidity of the right foot. Deep tendon reflexes appeared in the lower extremity. Sensation in the lower extremities became normal. The modified Frankel score was grade D. Saddle anesthesia and urinary retention were improved.

Figure 1.

A, Preoperative sagittal T2-weighted magnetic resonance imaging (MRI) of lumbar spine showing intense enhancement of lesion (white arrow). B, Preoperative axial MRI of L2 vertebra showing enhancement evincing an occupying lesion with high intensity over epidural at L2 (white arrow).

Figure 2.

A, Postoperative sagittal T1-weighted magnetic resonance imaging (MRI) of lumbar spine showing posterior approach (laminectomy) of L2 and L3 vertebrae (white arrow). B, Postoperative axial MRI of L2 vertebra showing a good assessment of the anterior lesion (white arrow).


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