An uncommon presentation of multiple spinal epidural abscesses: A case report

Abstract

Introduction

Spinal epidural abscess (SEA) is a rare but severe infection occurring in the epidural space of the spinal cord, increasingly associated with invasive spinal procedures and intravenous drug use. Recognizing and accurately diagnosing SEA is crucial due to its potential neurological impact.

Presentation of case

A 51-year-old male presented with urinary and bowel obstruction, right-sided hemiplegia, fever, and jaundice. Neurological examination revealed pronounced deficits, while imaging and cerebrospinal fluid analysis confirmed multiple epidural abscesses. Cultures identified Staphylococcus aureus sensitive to vancomycin and meropenem.

Discussion

The case underscores the variable presentations and nonspecific symptoms of SEA, highlighting the importance of an accurate medical history and timely imaging for diagnosis. Early intervention with surgical drainage and antibiotic therapy based on culture sensitivity is essential for improving outcomes.

Conclusion

This case emphasizes the need for heightened awareness of SEA, particularly in patients with risk factors, to ensure prompt diagnosis and treatment to prevent irreversible neurological damage.

Highlights

• •The diagnosis of multiple spinal epidural abscess can be further complicated.
• •Early diagnosis and treatment are crucial to provide the best outcomes of the patient
• •A high index of suspicion is necessary, particularly in patients presenting with atypical symptoms.

1. Introduction

Epidural abscess refers to an infection localized within the epidural space of the brain or spinal cord [1]. This condition arises from the introduction of infectious material into the epidural space between the dura mater and the vertebral periosteum [2,3]. The increasing frequency of SEA can be attributed to various factors such as the rising use of invasive spinal procedures, the aging population, and the growing incidence of intravenous drug use. Established risk factors for the development of spinal epidural abscess include immunosuppression, intravenous drug use, direct spinal instrumentation, and bacteremia. However, diabetes mellitus remains the most common predisposing factor [4]. Pain is the most consistent symptom reported by patients throughout the disease course. Fever and spinal discomfort are often the initial clinical manifestations, preceding an abrupt and potentially profound decline in neurological function [5]. The definitive diagnosis of a spinal epidural abscess necessitates drainage and microbiological analysis, which are informed by clinical suspicion and supported by imaging modalities, such as magnetic resonance imaging (MRI), alongside laboratory investigations [6]. Treatment typically involves decompressive surgery and abscess drainage, which is regarded as the gold standard in most cases. Additionally, it includes addressing the primary underlying infection (if identifiable) and administering intravenous antibiotics to target the likely pathogens. Most experts recommend treating posterior epidural abscesses through posterior laminectomy, removal of infected and granulation tissue, followed by normal saline irrigation. A drainage system is usually installed, and the abscess is irrigated for several days after surgery until the infection is fully resolved. In a selected group of patients who do not exhibit neurological deficits, or those with contraindications to surgery or a strong preference against it, SEA may be treated with high-dose antibiotics. However, caution should be exercised when opting for these non-surgical approaches [1]. In this article, we present an unusual case of a male patient with multiple epidural abscesses spanning the cervical, thoracic, and lumbar spinal regions.

2. Presentation of case

A 51-year-old male presented to the emergency department with a two-day history of bowel obstruction, followed by the development of right-sided focal hemiplegia, fever, and jaundice. His history was unremarkable for smoking, alcohol consumption, drug abuse, prior liver disease, hypertension, or any immunocompromising diseases, but family history was significant for chronic hepatitis B infection in his wife and daughters. He had normal anal function upon digital rectal examination, and normal fecal control, but previously experienced urinary retention one month prior, managed with a urinary catheter, but refused further investigation. The patient had no history of taking any medication other than daily vitamins and minerals supplements, and no remarkable history of past trauma or surgeries. Physical examination revealed fever (39 °C), tachycardia (heart rate of 110/min), hypertension (blood pressure of 160/90 mmHg), scleral icterus, pale conjunctiva, and mild hepatomegaly (3 cm below the costal margin). Neurological findings included muscle strength graded as 0/5 in the right extremities, 5/5 in the remaining extremities, diminished sensation in the lower limbs with a sensory level at the umbilicus, and a positive Babinski reflex in the right lower limb. Abdominal examination revealed a soft and distended abdomen with mild tenderness, mild hepatomegaly about 3 cm below the costal margin, but no guarding or rebound tenderness. Serum protein electrophoresis demonstrated decreased albumin levels alongside elevated polyclonal gammopathy and increased alpha-1 and alpha-2 globulins. MRI was conducted and revealed multiple spinal epidural abscesses (Fig. 1.1, Fig. 1.2, Fig. 1.3). A lumbar puncture was performed, and cerebrospinal fluid (CSF) analysis revealed a turbid appearance, with a yellow coloration. The examination quantified a white blood cell count of 1834 cells/cu mm, a red blood cells count of 1760 cells/cu mm, with neutrophils comprising 85 % and lymphocytes 13 %. Additionally, glucose levels were measured at 10 mg/dL, while protein content was elevated at 202 mg/dL, and CSF lactate scored 57,63 mg/dL. Laboratory blood tests findings are showed in (Table 1). Following resolution of ileus with enemas, dimethicone, and fluid replacement, empirical antibiotic therapy with meropenem 2 g/3/day, vancomycin 1 g/2/day, and metronidazole 500 mg/3/day was administered for 20 days. Assessment following empirical therapy revealed a right upper limb strength of 3/5 and a right lower limb strength of 0/5, accompanied by normal bowel function. Following this assessment, the decision to undergo surgery was referred, and the patient subsequently underwent surgical intervention involving a midline incision between L2 and L4, followed by meticulous dissection of subcutaneous tissue and fascia to expose the spinous processes. A laminectomy was performed at the L2, L3, and L4 vertebrae, during which purulent fluid was noted without a discernible abscess wall. A specimen was obtained for bacterial culture, and the surgical site was thoroughly irrigated with normal saline before the closure of the skin layers. Culture results from the purulent fluid identified Staphylococcus aureus, with sensitivity to vancomycin and meropenem, prompting the continuation of antibiotic therapy with these agents at the same dosage for four weeks, and the discontinuation of metronidazole. Postoperatively, the patient exhibited an improvement in motor strength in the right lower limb, now rated at 3/5, along with normal sensory function in the lower extremities and repeated MRI during follow-up after demonstrated the absence of any signs of abscess or inflammatory changes (Fig. 2). We have provided a clinical timeline summarizing the events of our case (refer to Fig. 3).

Fig. 1.1.

MRI image (sagital view) of the cervical region shows an abscess within the spinal canal in front of the spinal cord.

Fig. 1.2.

MRI images of the thoracic region (sagital and axial view) showing an abscess within the spinal canal pressing the spinal cord backward.

Fig. 1.3.

MRI images of the lumbar region (sagital and axial view) showing an abscess in front of the nerve roots compressing the spinal cord posteriorly.

Table 1.

Laboratory tests results.

Test	Result	Normal ranges
Complete blood count (CBC)
White blood cells (WBC)	13.4 × 103/mm3	4.0–11.0 × 103/mm3
Neutrophils	94 % (left shift)	∼40.75 %
Red blood cells (RBC)	3.02 × 106/mm3	4.7–6.1 × 106/mm3
Hemoglobin (HGB)	9.6 g/dL	13.8–17.2 g/dL (males)
Platelets (PLT)	270 × 103/mm3	150–450 × 103/mm3
Kidney function
Creatinine (Cr)	0.7 mg/dL	0.6–1.2 mg/dL
Electrolytes	Within normal limits
Liver function tests
Alanine aminotransferase (ALT)	156 U/L	7–56 U/L
Aspartate aminotransferase (AST)	120 U/L	10–40 U/L
Total bilirubin	12 mg/dL	0.1–1.2 mg/dL
Direct bilirubin	7 mg/dL	0.0–0.3 mg/dL
Albumin	3 g/dL	3.5–5.0 g/dL
INR	1.6	∼1.0 (higher in liver disease)
Viral hepatitis markers
Hepatitis A virus antibodies	Negative
Hepatitis C virus antibodies	Negative
Hepatitis B surface antigen (HBsAg)	Positive
HBe antigen	Negative (0.1)
Anti-HBc	Negative (0.2)
HBV DNA (PCR)	Undetectable
Alpha-Fetoprotein (AFP)	Negative (0.9)	<10 ng/mL

Fig. 2.

MRI images during follow-up after treatment show absence of any signs of abscess or inflammatory changes in: the thoracic region (as shown in image A), and the cervical region (as clear in image B), as well as the lumbar and sacral region (as illustrated in images C, D and E).

FIg. 3.

Clinical timeline summarizing the events of the case.

3. Discussion

SEA is a rare but serious suppurative infection associated with substantial morbidity and potential mortality [2]. SEA can develop when bacteria enter the epidural space due to a nearby infection (such as a psoas muscle abscess, osteomyelitis, or skin infection), or through direct introduction (for instance, via steroid injections, surgical procedures, nerve blocks, or acupuncture) [7]. However, the bacteria typically access the epidural space through hematogenous spread [4]. Several risk factors predispose individuals to SEA, including diabetes mellitus, alcoholism, bacteremia, contiguous infections, cirrhosis, end-stage renal disease, HIV infection, chronic immunosuppressive conditions, increased spine-related interventions, and advancements in diagnostic techniques [4,6,8]. Cases of SEA following chemoradiation therapy for esophageal cancer had also been documented [9], and notably, the first case of SEA after chemotherapy for breast cancer was reported earlier this year [2]. Remarkably, our patient had no predisposing factors. SEA remains an infrequent diagnosis, with an estimated incidence of approximately 2 to 8 cases per 10,000 hospital admissions [4]. The typical clinical presentation involves a triad of fever, back pain, and neurological deficit, although this combination is observed in only 8 to 15 % of cases [4]. The manifestations of SEA vary significantly among affected individuals. (Table 2) provides a summary of the approximate incidence of each symptom or sign according to a study of 106 patients [10]. The patient presented to the emergency department with signs of neurological impairment, characterized initially by urinary retention and bowel obstruction persisting for two days. Subsequently, he experienced a sensation of heaviness in the right upper and lower extremities. During this period, he developed scleral icterus, conjunctival pallor, and fever. Following admission to the gastroenterology department and subsequent neurological consultation, the clinical findings were as follows:

• -Alert, responsive, and oriented status
• -Right-sided sensory and motor hemiparesis rated at 0/5
• -Sensory level at the umbilicus
• -Positive right Babinski reflex

Despite back pain being the most common symptom of SEA, our patient did not experience this complaint. Even in early presentations of SEA, clinical symptoms often remain nonspecific, particularly when broader clinical context is not considered [11]. Therefore, a thorough assessment of the patient's medical history to identify the risk factors enhances diagnostic accuracy. The pain associated with epidural abscesses is typically severe and refractory to conventional treatments. Among affected patients, 90 % develop radicular pain within days of the onset of spinal tenderness, often accompanied by fever exceeding 38 °C. Other nonspecific symptoms may include generalized fatigue, headache, irritability, and vomiting. Initial back pain can persist for several weeks, with progression to radicular pain occurring within 3 to 4 days. Subsequently, spinal cord dysfunction emerges over the next four to five days. At this stage, neurological deficits may remain reversible, though urgent surgical intervention may be necessary, as complete paralysis can develop rapidly within hours [1]. The interval between symptom onset and seeking medical attention varies widely, ranging from a few days to over a month [11]. The severity of neurological decline depends on the spinal cord level involved [1]. The natural progression of SEA has been classified into four distinct stages:

• -Stage 1: Spinal tenderness, fever, or back pain
• -Stage 2: Nuchal stiffness and radicular discomfort
• -Stage 3: Neurological deficits
• -Stage 4: Paralysis, observed in approximately 34 % of cases

Among affected individuals, only 8–15 % exhibit the classical triad of neurological decline, fever, and back pain [4]. Clinicians must evaluate all patients presenting with febrile illness, localized spinal pain, and acute or worsening back pain for potential SEA. The diagnosis should be considered promptly, despite the variability and occasionally obscure presentation. Not all patients exhibit typical features; pediatric cases, in particular, may present with atypical findings. Fever and systemic manifestations may be muted in individuals with chronic SEA. According to published research, nearly half of SEA patients receive an initial misdiagnosis [4]. Patients may fail to recognize or report subtle symptoms such as motor weakness, bowel and bladder dysfunction, which necessitate proactive clinical inquiry [11]. Laboratory findings often remain nonspecific, with mild leukocytosis and elevated C-reactive protein levels being common. CSF lactate levels, that are normally (1–3 mmol/L), usually are elevated in such cases [12]. Blood cultures frequently return positive in SEA cases, whereas intracranial epidural abscess (IEA) blood cultures generally remain negative. Due to the rarity of bone involvement in SEA, conventional spinal radiography is typically unhelpful. MRI has largely replaced myelography as the gold standard for SEA diagnosis, offering sensitivity exceeding 90 % [1]. MRI facilitates management decisions, distinguishes SEA from differential diagnoses, and delineates the extent of disease involvement. Radiographic findings may include disk space narrowing and bone lysis on simple roentgenogram or CT imaging. MRI of our patient demonstrated multiple spinal epidural abscesses. CSF studies typically reveal pleocytosis and elevated protein concentrations, consistent with parameningeal inflammation. However, CSF cultures yield positive results in only 25 % of cases and are now reserved for instances requiring myelography due to associated risks of meningitis or subdural infection. CT-guided needle aspiration and blood cultures provide high diagnostic yields. Notably, nearly all patients with positive CSF cultures also exhibit positive blood cultures. In 78.8 to 90.5 % of cases, open or minimally invasive surgical procedures yield positive bacterial cultures [4]. The patient presented with recurrent urinary retention, bowel obstruction, right upper limb heaviness, jaundice, and fever. Neurological and laboratory findings indicated SEA with Staphylococcus aureus abscesses in the spinal cord. Due to the rarity and severity of SEA, prospective randomized clinical trials assessing optimal therapeutic strategies remain impractical and ethically challenging. Nonetheless, surgical drainage, decompressive laminectomy, and infected tissue removal combined with systemic antibiotic therapy constitute the cornerstone of SEA management [4,6,9,13]. Surgical treatment involves the emergency drainage of purulence while relieving pressure on the spinal cord and nerve roots. When paraparesis is present, the outcome is influenced by the duration between the onset of symptoms and the surgical intervention. Generally, a longer delay results in more significant long-term consequences [5]. Antibiotic selection should be guided by culture susceptibility testing, with treatment duration extending for at least six weeks. Empirical therapy should encompass coverage against staphylococci (typically vancomycin for MRSA) and gram-negative bacilli (such as third- or fourth-generation cephalosporins like ceftazidime or cefepime), particularly when gram-negative infection from other sites, such as the urinary tract, is suspected [4,6]. As a post-operative therapy, intravenous antibiotics are administered for six weeks, although recent guidelines recommend extending the total intravenous antibiotic therapy to eight weeks for patients with resistant organisms like MRSA. After this period, patients switch to oral suppressive antibiotics [14]. Our patient initially received conventional enemas, dimethicone, and intravenous fluid replacement, followed by a 20-day course of empirical intravenous meropenem and vancomycin, as well as metronidazole as a preventive measure against amoebic infections since it is common in our region, leading to partial neurological improvement and normalization of bowel function. Subsequently, surgical intervention was performed, including laminectomy for L2–L4, drainage of purulent fluid, and post-culture targeted antibiotic therapy of meropenem and vancomycin for four weeks, resulting in improved motor strength and restored sensation in the lower extremities.

Table 2.

Distribution of common clinical manifestations observed in a cohort of 106 patients diagnosed with SEA.

Frequency, no. (%)*	Sign or symptom
48 (47.1)	Back pain
8 (7.8)	Neck pain
25 (24.5)	Acute
23 (22.5)	Progressively worsening
34 (33)	Fevers/chills
13 (12.7)	Altered mental status/lethargy
48 (47.1)	Focal neurological findings
25 (24.5)	Paralysis/paresis in extremities
23 (22.5)	Paresthesia/pain in extremities
5 (4.9)	Nausea/vomiting
18 (17.6)	Urinary/bowel symptoms

4. Conclusion

In summary, this case highlights the diagnostic challenges and clinical variability of spinal epidural abscess especially when accompanied by atypical presentations, emphasizing the importance of early recognition and prompt intervention. Given the potential for rapid neurological deterioration, a high index of suspicion is necessary, particularly in patients presenting with atypical symptoms. Timely surgical decompression, combined with prolonged targeted antimicrobial therapy, remains essential to optimizing patient outcomes. This case underscores the need for continued vigilance in diagnosing SEA and reinforces the critical role of multidisciplinary collaboration in managing complex spinal infections.

List of abbreviations

SEA

spinal epidural abscess

MRI

magnetic resonance imaging

CSF

cerebrospinal fluid

IEA

intracranial epidural abscess

Author contribution

Saja Karaja, Shafiq Alassaf, Ahed Assaf, Elias Tannous, Rima Alassaad: Data Curation, Writing – review & editing, Writing – original draft.

Ghiath Alassad: Writing – review & editing, Supervision.

All authors read and approved the final manuscript.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Ethical approval

Not applicable.

Guarantor

Ghiath Alassad.

Research registration number

Not applicable.

Methods

The Work has been reported in line with SCARE criteria [15].

Declaration of Generative AI and AI-assisted technologies in the writing process

None.

Funding

No funding was provided for this study.

Conflict of interest statement

The authors declare no conflicts of interests.