Hospital: Hospital Universitario Morales Meseguer.
Ciudad:
Nº:
Aut@r o Autores: J. Trejo Falcón, A. Blanco Barrio, B. Marquez Argente Del Castillo, M. Lozano Ros, A. Garcia Chiclano, A. Barcelo Carceles.,
Presentación:
A 68-year-old man with chronic alcoholism was admitted with upper gastrointestinal bleeding. During admission, he had S. aureus bacteremia and developed abscesses in the right trapezius and deltoid muscles, diagnosed by ultrasound, that were surgically drained. Despite this, fever and laboratory findings consistent with ongoing infection persisted. He had complained of sacral and lower limb pain since admission two weeks earlier. Suddenly he developed neurological deficit (feet paresthesia and perineal anesthesia). An urgent MRI of the lumbosacral spine was performed. An anterior epidural collection extending from L3 to L5 was depicted compressing the thecal sac. It showed high T2, low T1 signal, and rim enhancement after IV GD injection, consistent with an abscess. No signs of diskitis-osteomyelitis were seen. Additionally, an abscess in the left iliopsoas muscle was partially depicted. CT was performed to evaluate its extension and rule out other sites of infection. The patient underwent urgent percutaneous CT-guided drainage of the psoas abscess and spinal surgery.
Discusión:
Diagnosis: metastatic S. aureus infection with spinal epidural abscess and multifocal soft tissue abscesses. S. aureus is a leading cause of community and hospital acquired bacteremia. Patients with S. aureus bacteremia can develop many complications that may be difficult to recognize initially and can increase morbi-mortality. Metastatic infection can occur in up to 30% of cases and affect many organs (vertebral osteomyelitis, diskitis, epidural abscess, endocarditis, soft tissue abscess, brain septic emboli, etc.). Soft-tissue abscesses often present with few symptoms and may go unnoticed. Spinal epidural abscesses are uncommon with an estimated incidence of 2-3 per 10,000 hospital admissions. Special attention must be paid to patients with risk factors (diabetes mellitus, alcoholism, HIV infection, spinal trauma, surgery or degenerative joint disease, IV drug users…) when “red flags” are present. Imaging should be tailored to the red flags on physical examination though CT of the torso is recommended for patients with endocarditis even in the absence of focal symptoms, searching for subclinical sites of metastatic infection. With the onset of neurological symptoms, MRI is the test of choice. In the presence of a pyogenic lumbar abscess, it is convenient to extend the study to the cervical and dorsal spine due to the high risk of dissemination.
Conclusión:
Diagnosis: metastatic S. aureus infection with spinal epidural abscess and multifocal soft tissue abscesses. S. aureus is a leading cause of community and hospital acquired bacteremia. Patients with S. aureus bacteremia can develop many complications that may be difficult to recognize initially and can increase morbi-mortality. Metastatic infection can occur in up to 30% of cases and affect many organs (vertebral osteomyelitis, diskitis, epidural abscess, endocarditis, soft tissue abscess, brain septic emboli, etc.). Soft-tissue abscesses often present with few symptoms and may go unnoticed. Spinal epidural abscesses are uncommon with an estimated incidence of 2-3 per 10,000 hospital admissions. Special attention must be paid to patients with risk factors (diabetes mellitus, alcoholism, HIV infection, spinal trauma, surgery or degenerative joint disease, IV drug users…) when “red flags” are present. Imaging should be tailored to the red flags on physical examination though CT of the torso is recommended for patients with endocarditis even in the absence of focal symptoms, searching for subclinical sites of metastatic infection. With the onset of neurological symptoms, MRI is the test of choice. In the presence of a pyogenic lumbar abscess, it is convenient to extend the study to the cervical and dorsal spine due to the high risk of dissemination.
Bibliografía:
– Diehn FE. Imaging of spine infection. Radiol Clin North Am 2012, 50:777–98. – Fowler VG. Clinical approach to Staphylococcus aureus bacteremia in adults. UpToDate Inc. (Accessed on February 09, 2019).