Presentation
5 day history of midthoracic back pain associated with right upper limb weakness, bladder retention, truncal ataxia and increased lower limb tone.
Patient Data
Key Findings
Expansion of the cervical cord from a peripherally enhancing lesion which extends for a distance of approximately 7.6 cm between C4 and T1.
The cervical cord between the levels of C4 and C7/T1, there is a heterogeneous T2-hyperintense lesion which expands the cord. It measures up to 7.4 x 7.1 mm in the axial plane at C6 and extends for a distance of approximately 7.6 cm. The lesion is predominantly hypointense on T1 and demonstrates thick peripheral enhancement. The rim of the lesion demonstrates T2 hypointensity. There is increased T2 signal extending superiorly to the cervical medullary junction and inferiorly to approximately the level of T6, involving predominantly central grey matter of the cord.
Relevant Negatives
No other cord lesions are identified. No evidence of discitis or vertebral body osteomyelitis. No extradural collection identified. The conus terminates at L1.
Differentials
In the correct clinical context, the findings are compatible with a spinal cord abscess, although this is an uncommon entity. The findings are more likely those of a spinal cord tumor (?ependymoma or less likely lymphoma) possibly with hemorrhage accounting for the non-enhancing, T2 intense central portion & rapid progression of symptoms. The appearance is not typical for a demyelinating plaque given the extent and the presence of cord expansion.
Post op imaging following laminectomy and drainage of cord abscess.
Microbiology
DIRECT EXAMINATION
Wet Preparation: No fungal elements detected
GRAM STAIN Leukocytes +++ Gram positive cocci +++ Gram positive bacilli +++ Gram negative bacilli +++
CULTURE 1. Aggregatibacter aphrophilus ++ 2. Streptococcus anginosus group (milleri group) ++
SENSITIVITIES 1 2 Ceftriaxone S S Penicillin S S
Case Discussion
An intramedullary spinal cord abscess (ISCAs) is a rare infectious pathology with fewer than 100 cases reported in the medical literature. It can be primary (spontaneous) or secondary to infectious extension/rupture of an epidural abscess. ISCAs present with a subacute course of neurological symptoms consistent with cord compression.
MRI with contrast is the imaging modality of choice.
Management would include: dexamethasone, surgical decompression, specimen culture, and antibiotics. Staphylococcus, streptococcus, anaerobic and microaerophilic organisms have been cultured in reported cases.
In a patient with a history of recurrent meningitis who presents with acute transverse myelitis, a congenital dermal sinus with an intramedullary abscess should be suspected.