Case Presentation: A 31-year-old healthy man presented with several days of chest and back pain associated with shortness of breath, subjective fever, headache, and photophobia. The patient worked in construction and complained of a recent itchy, vesicular rash to his forearm. Review of systems was otherwise negative for recent procedures or surgeries, IV drug use, sick contacts, travel, new sexual partners, and animal or insect bites.In the ED, the patient was afebrile with a heart rate of 121 beats per minute. Vital signs were otherwise stable. On exam, he was ill-appearing with nuchal rigidity, positive Brudzinski sign, and tenderness to palpation of his right mid-thoracic paraspinal muscles. White blood cell count was 16,100/µL with 86% neutrophils. Liver and renal function tests were normal. CRP and ESR were significantly elevated at 333.4 mg/L and > 130 mm/HR, respectively. A lumbar puncture revealed 302 total nucleated cells, 119 protein, normal glucose, and rare polymorphonuclear leukocytes. HIV antibody was negative. Chest radiograph and magnetic resonance imaging (MRI) of the brain were both unrevealing. Given his recent forearm rash, the patient was started on IV vancomycin and ceftriaxone for presumed Lyme meningitis. Within 24 hours, blood cultures resulted positive for methicillin-sensitive staph aureus (MSSA) in 1 out of 2 bottles. Persistent back pain, elevated inflammatory markers, and bacteremia raised our suspicion for possible spinal epidural abscess (SEA). An MRI thoracic spine with contrast ultimately revealed dorsal T1-T4 epidural abscess with cord compression most predominant at T3. The patient underwent incision and drainage, epidural abscess evacuation, and laminectomy with orthopedic surgery.Further cardiac work-up was unrevealing for endocarditis and repeat blood cultures remained clear. The patient improved clinically and was discharged home on six weeks of IV nafcillin.
Discussion: Spinal epidural abscess is rare but can be fatal if left untreated. SEA poses a diagnostic challenge for hospitalists, as presentations can differ from non-specific to severe, ranging from isolated back pain to meningitis or sepsis. The most common presenting symptoms are midline back pain and fever [1]. Importantly, only 33% of patients have neurological deficits [1]. As evidenced by our patient, the triad of fever, back pain, and elevated inflammatory markers can offer an algorithmic approach to diagnosing SEA in hospitalized patients [2]. Risk factors for SEA include an immunocompromised state, recent spinal procedures, IV drug use, and bacteremia [2]. Although diabetes mellitus is the leading risk factor, no predisposing condition is found in roughly 20% of patients diagnosed with SEA [2]. Inpatient providers should be aware of the full spectrum of disease associated with SEA, as prompt diagnosis and treatment are essential to preventing permanent neurological damage and death. Modern radiologic techniques, specifically MRI, have aided significantly in the timely diagnosis of SEA [2].
Conclusions: Spinal epidural abscess should be considered in all patients with back pain and fever, including those without neurological deficits or traditional risk factors. Elevated inflammatory markers should further raise a hospitalist’s suspicion. Acting swiftly to diagnose SEA is the most important factor in reducing morbidity and mortality. MRI serves as a sensitive tool for diagnosis.