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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 2  |  Issue : 2  |  Page : 65-67
A rare case of spinal epidural abscess due to Mycobacterium tuberculosis in a 15-year-old girl


Department of Microbiology, Lokmanya Tilak Municipal Medical College General Hospital, Sion, Mumbai- 400002, India

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Date of Web Publication10-Jun-2010
 

   Abstract 

Clinical infection of spinal epidural space is a rare infectious disorder that often has delayed diagnosis and is associated with significant morbidity and mortality. Initial clinical presentation may be fever, low backache that is non- specific and may mimic urinary tract infection, malignancy, and neuralgia. Hence, a high index of suspicion is required to diagnose such cases. MRI and diagnostic aspiration is necessary so that the pathogen-directed therapy could be instituted to prevent mortality. Most reported cases occur in the age group of 40-60 years, with very few reported in younger age groups. Most commonest pathogen reported is Staphylococcus aureus, and only few cases due to Mycobacterium tuberculosis are reported. Here, we report a case of epidural abscess in a 15-year-old female caused by M. tuberculosis. The diagnosis was done by MRI scan and microbiological investigations on the aspirated pus. The patient was responding to combination therapy i.e. surgical drainage and chemotherapy when last follow-up was taken.

Keywords: Mycobacterium tuberculosis , spinal epidural abscess

How to cite this article:
Wanjari K, Baradkar V P, Mathur M, Kumar S. A rare case of spinal epidural abscess due to Mycobacterium tuberculosis in a 15-year-old girl. Ann Trop Med Public Health 2009;2:65-7

How to cite this URL:
Wanjari K, Baradkar V P, Mathur M, Kumar S. A rare case of spinal epidural abscess due to Mycobacterium tuberculosis in a 15-year-old girl. Ann Trop Med Public Health [serial online] 2009 [cited 2018 Nov 17];2:65-7. Available from: http://www.atmph.org/text.asp?2009/2/2/65/64280

   Introduction Top


Spinal epidural abscess (SEA) was first described in 1976. It is a severe pyogenic infection of the epidural space, which frequently requires neurosurgical intervention for etiological diagnosis in order to avoid permanent neurological damage. [1] Epidural abscess is seldom encountered, although when present, it is often devastating. Spontaneous epidural occurs in 0.2-1.3 per 10,000 hospital admissions and typically affects immunosupressed patients. [2] Most of the cases occur in patients aged 30-60 years and rarely in the younger age group. [2] The most common causative agent is Staphylococcus aureus, and few cases are reported due to Streptococcus milleri[3] and Mycobacterium tuberculosis. [1],[4],[5],[6] Associated predisposing factors for the development of epidural abscess include spinal procedures performed, [7] intravenous drug abuse, AIDS, [1] alcoholism, diabetes mellitus, chronic renal failure, malignancy, and spinal trauma. [7] However, this condition has also been reported in patients with no predisposing factors. Clinical features suggestive of epidural abscess include fever, back pain, spinal tenderness, neurological deficit including muscle weakness, sphincter incontinence as well as sensory deficits. [1],[2],[3],[4],[5],[6],[7]

Here, we report a rare case of epidural abscess due to M. tuberculosis in a 15-year-old female confirmed by MRI scan, Ziehl Neelsen staining, and culture.


   Case Report Top


A 15-year-old female presented with a history of fever, low back ache, loss of power of lower extremities since 2 months, and with reduced appetite since the past 1 month. The patient had a past history of pulmonary tuberculosis 2 years back, for which she had received antitubercular treatment for a period of 18 months, after which she was declared cured with the resolution of pulmonary lesions and the sputum being negative for acid fast bacilli. At present, there was no history of cough. The patient was HIV seronegative, non-diabetic and there was no history any surgery performed or trauma.

On examination, the patient was febrile (102ο F) and tenderness was present on the back. The pulse was 110/min, B.P. 110/80 mmHg. The cardiovascular and respiratory systems were within normal limits. Neurologically, the power of the lower extremity muscles was decreased on both the sides. The knee and ankle jerk were exaggerated and the plantars were up, bilaterally. Patellar clonus was present, with hypoesthesia below D 9 level. The chest x-ray was within normal limits. Other investigations showed Hb 12.9 g/dL, total leukocyte count of 98,000 (polymorphs 60% and lymphocytes 40%), BUN 12 mg%, total bilirubin 0.5 mg/dL, SGOT 23 IU/L, SGPT 34 IU/L.

MRI scan was performed [Figure 1] which showed thick epidural soft tissue noted from D2 to D12 level compressing the spinal cord resulting in cord edema and ischemia from D3 to D8 level. Abnormal associated soft tissue was seen on D7 to D11 [Figure 2] with involvement of adjacent ribs. Abnormal soft tissue was also seen in the posterior and right paraspinal and dorsolumbar regions representing granulation tissue.

The patient underwent surgical decompression (laminectomy) and debridement. Surgical findings were of pus and granulation tissue in the epidural space. The pus was sent for microbiological investigations, which revealed acid fast bacilli on Ziehl Neelsen staining, and culture on Lowenstein Jensen media showed the buff and tuff colonies of M. tuberculosis after 3 weeks of incubation. The patient was started on Category I: DOTS therapy i.e. 2H 3 R 3 Z 3 E 3 (H: Isoniazid (600 mg), R: Rifampicin (450 mg), Z: Pyrazinamide (1500 mg), Ethambutol (1200 mg) for 2 months), followed by 4H 3 R 3 (H: Isoniazid (600 mg), R: Rifampicin (450 mg)), for a period of 4 months. The patient was responding well to the treatment when last follow-up was taken 4 months after treatment, with almost complete recovery of the power of the lower limbs with no residual neurological deficits.


   Discussion Top


Epidural abscess is most common in the age group of 30-60 years, while it is rare in the younger age group. [4] In this case, the patient was a 15-year-old female. There was no underlying predisposing factor except that there was a past history of pulmonary tuberculosis, for which the patient had taken antitubercular treatment, after which the sputum was negative and there was resolution of the pulmonary lesions.

Tuberculosis of the spine accounts for 1% of all tuberculosis infections. M. tuberculosis infection generally spreads to the spine by the hematogenous route or paraspinal extension. Any level of spine may be affected, but lesions are more commonly found in the thoracic region; the cervical and lumbar areas are less frequently involved, as observed in the present case.

S. aureus[1],[2],[3],[4],[5],[6] is the most common organism responsible for epidural abscess, and few cases are reported due to M. tuberculosis. [1],[4],[5],[6] Koppel et al. [8] reported 18 cases of SEA with disc space infection, amongst which 2 were due to M. tuberculosis. Two most common pathogens found in 29 patients with diagnosis ofSEA, who were analyzed by Lu et al., [9] were S. aureus and M. tuberculosis (62%). MRI findings and histopatholgical analysis revealed the abscess to be due to M. tuberculosis. The patient responded to decompression and antitubercular therapy.

Although M. tuberculosis is an infrequent pathogen in western countries, it is still common in developing countries. [9] A history of fever, night sweats, elevated WBC counts is reported to be common in pyogenic as well as tubercular cases. Most common signs and symptoms of SEA reported are initially backache (71%) and fever (66%) as initial symptoms [4] followed by neurological deficits including muscle weakness. [4] In our case, the patient presented with fever, backache, and muscle weakness of lower extremity. Tubercular SEA usually occurs secondary to tuberculous spondylitis and has been reported in immunodeficient persons and as reactivation of dormant focus. 10 Probably this might be the cause in the present case. A dormant lesion might have remained which probably led to epidural abscess as the patient had a past history of pulmonary tuberculosis.

MRI is the method of choice for diagnosis of SEA. In comparison to pyogenic abscess, SEA due to M. tuberculosis is characterized by a predilection for spinal deformity, subligamentous spread, and contiguous multilevel involvement as in our patient. Spinal tuberculosis should be [4] distinguished from malignant metastatic lesions. Metastatic lesions characteristically spare the disc space and they may involve multiple non-contiguous vertebra, which does not occur in spinal tuberculosis. Paravertebral and epidural abscesses, and subligamentous spread are more frequent in tuberculosis. [1] Tuberculous SEA can be treated conservatively with antitubercular treatment, unless there are specific indications for surgery. Indications for surgery include:

  1. Neurological deficit (less than Grade 5; by the 5 point grading system);
  2. Neurological worsening, while on antitubercular treatment,
  3. Doubtful diagnosis on clinicoradiological evaluation and
  4. Significant kyphosis (greater than 40 degrees at presentation).
Surgical treatment involves laminectomy and drainage of the abscess. [4]

Despite the advances in therapy and diagnostic imaging, mortality due to SEA remains high, ranging from 18 to 30% in modern studies. High morbidity and mortality rates have been usually related to delays in both early diagnosis and institution of definitive therapy. Patients with mycobacterial spinal infection have better outcomes compared with those with nontuberculous mycobacterial infection. [4]

SEA is a severe complication that requires urgent neurosurgical procedure combined with antitubercular therapy. This is the treatment of choice to avoid neurosurgical sequelae. Age, early diagnosis and treatment, and the degree of involvement are the most important prognostic factors in patients with SEA.

We conclude that M. tuberculosis should be included in the differential etiology of SEA. The high index of suspicion is required to diagnose the case of epidural abscess specially in younger age groups, when the patient presents with fever, backache being a non-specific symptom may mimic UTI, malignancy, and neuralgia.

 
   References Top

1.Metta H, Corti M, Redini L, Yampolsky C, Schtirbu R. Spinal epidural abscess due to Mycobacterium tuberculosis in a patient with AIDS: Case report and review of the literature. Braz J Infect Dis 2006;10:146-8.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Reihsaus E, Waldbaur H, Seeling W. Spinal Spinal epidural abscess: A meta-analysis of 915 patients. Neurosurg Rev 2000;23:175-204.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Parkinson JF, Sekhon LHS. Spinal epidural abscess: Appearance on magnetic resonance imaging as a guide to surgical management. Report of 5 cases. Neurosurg Focus 2004;17:1-6.  Back to cited text no. 3      
4.Shameem M, Bhargava R, Ahmed Z, Shah NN, Haque F, Abas Z, Ameer S. Epidural extension of tuberculosis Empyema thoracis causing cord compression. Ind J Chest Dis Allied Sci 2007;49:107-10.  Back to cited text no. 4      
5.Khattry N, Thulkar S, Das A, Khan SA, Bakshi S. Spinal tuberculosis mimicking malignancy: Atypical imaging features. Ind J Pediatrics 2007;74:297-8.  Back to cited text no. 5      
6.Locham KK, Garg R, Singh M. Tuberculosis of lower cervical spine. Ind Pediatrics 2001;38:546-9.  Back to cited text no. 6      
7.Vilke GM, Honinford EA. Cervical spine epidural abscess in a patient with no predisposing risk factor. Ann Emerg Med 1996;27:777-80.  Back to cited text no. 7      
8.Koppel BS, Tuchman AJ, Mangiardi JR. Epidural spinal infection in intravenous drug abusers. Arch Neurol 1988;45:1331-7.  Back to cited text no. 8      
9.Luc H, Chang WN, Lui CC. Adult spinal epidural abscess: Clinical features and prognostic factors. Clin Neurol Neurosurg 2002;104:306-10.  Back to cited text no. 9      

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Correspondence Address:
V P Baradkar
Department of Microbiology, L.T.M.M.C and L.T.M.G.H, Sion, Mumbai-400022,
India
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Source of Support: None, Conflict of Interest: None


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    Figures

  [Figure 1], [Figure 2]

This article has been cited by
1 result 1 Document Spondilodiscitis due to Mycobacterium tuberculosis in HIV and non-HIV-infected patients: Eleven years experience in a referent Hospital of infectious diseases in Argentina
Authors of Document Corti, M., Villafañe, M.F., Trione, N., Yampolsky, C., Gilardi, L.
Source of the Document Annals of Tropical Medicine and Public Health. 2012;
[Pubmed]
2 Tubercular epidural abscess with cervical localisation: Complete regression with drug therapy
Kumar, A., Singh, P., sirohi, B., Jain, P., Badole, C.M.
Indian Journal of Medical Specialities. 2011; 2(1)
[Pubmed]



 

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