Radiological Case: Acute Quadriplegia in a Patient With Bacterial Pericarditis

Payam Sajedi, MD; Rinal Choksi, BS; Prashant Raghavan, MBBS


Appl Radiol. 2017;46(2) 

In This Article

Imaging Findings

Magnetic resonance imaging (MRI) of the thoracic spine demonstrated heterogeneous STIR-weighted signal abnormality involving the T1 to T3 levels with extensive surrounding edema. T1-weighted imaging demonstrated corresponding hypointense signal abnormality. Post-contrast imaging revealed a thin rim of enhancement surrounding the lesion (Figure 1). There was no evidence of spondylodiscitis or epidural abscess. Given the rapid clinical presentation, these findings raised the suspicion for an intramedullary spinal cord abscess (ISCA).

Figure 1.

Contrast-enhanced cervical and upper thoracic spine MRI. (A) Sagittal STIR view demonstrates heterogeneous areas of increased STIR signal (white arrows) involving the upper thoracic cord with extensive STIR hyperintensity in the visualized lower cervical cord (blue arrows). (B) Sagittal T1 fat-saturated post-contrast view reveals a centrally necrotic (blue arrows), peripherally enhancing intramedullary spinal cord lesion spanning T1-T3 (white arrows), suggestive of abscess formation.

Subsequent computed tomography (CT) of the chest, abdomen, and pelvis demonstrated a peripherally enhancing fluid collection in the subcarinal/paraesophageal region worrisome for suppurative lymph node/abscess (Figure 2). No additional sources of infection were identified.

Figure 2.

Contrast-enhanced chest CT. Axial (A) and coronal (B) views show an ill-defined, low attenuation structure with dense rim in the subcarinal/paraesophageal region (arrow) concerning for suppurative lymphadenopathy/abscess.

The patient developed complete quadriplegia with fecal incontinence soon after the MRI. An emergent decompression of the thoracic spine was performed with an intraoperative ultrasound confirming liquefied material within the upper thoracic spinal cord, compatible with intramedullary abscess formation. Myelotomy resulted in drainage of purulent fluid. Following the procedure, intravenous vancomycin, cefepime, and a steroid regimen were initiated. Cultures from the purulent material were positive for Streptococcus viridans.

Postoperatively, the patient regained partial return of upper extremity motor function, though demonstrated persistent paraplegia with persistent hypoesthesia below the nipple line. He was ultimately discharged to a rehabilitation center where physical and occupational therapy were initiated.