Protean infectious types and frequent association with neurosurgical procedures in adult Serratia marcescens CNS infections: report of two cases and review of the literature

Serratia marcescens is a rare pathogen of adult central nervous system (CNS) infection. We report on the clinical features and therapeutic outcomes of two adult patients with such infections. The clinical characteristics of 13 other reported adult cases are also included for analysis. The 15 cases were nine males and six females, aged 19-83 years, in whom, underlying post-neurosurgical states and ear operation were noted in 93% (14/15). Fever and conscious disturbance were the most common clinical manifestations of these 15 cases, followed by hydrocephalus, seizures, and wound infections. The manifestation types were protean, including meningitis and focal suppurations such as brain abscess, cranial and spinal epidural abscess, cranial subdural abscess, and infected lumbar pseudomeningocele. One case of S. marcescens CNS infection was diagnosed postmortem; the other 14 were diagnosed by the positive culture from CSF or pus. Antibiotic therapy with or without neurosurgical intervention was the management strategy in 14/15 cases. The therapeutic results showed a high mortality rate.     

MRI detection of epidural spinal abscesses at noncontiguous sites

We report the cases of two patients with the very uncommon clinical finding of two noncontiguous spinal epidural abscesses, which were located in the cervical and lumbar spine. In each case the diagnosis of the second spinal abscess was made by MRI only after the appearance of a new neurological deficit. Decompressive spinal surgery and intravenous antibiotic therapy led to complete recovery in one patient; the other patient was moderately disabled. As epidural spinal abscesses can occur at noncontiguous sites, MRI of the entire spine may be necessary in selected cases.     

Hyperbaric oxygen therapy for the treatment of brain abscess in children

Introduction The treatment of brain abscess remains a challenging topic usually involving a multimodal concept.Methods We report our experience with hyperbaric oxygen (HBO) therapy in five children presenting with brain abscesses between 1995 and 2002 at the Department of Neurosurgery, Graz. Mean age was 14.8 (range 11–17 years). All abscesses were located supratentorially. One child had a single abscess and one had multilocated abscesses. Two other patients presented with both subdural empyema and brain abscess, one of them showing an epidural empyema as well. In another child, the brain abscess was associated with meningoencephalitis and subdural empyema. In all of them the underlying condition was spread of infection from the paranasal sinuses, except for one, who was immunocompromised due to cytotoxic chemotherapy for acute lymphocytic leukaemia.Results One single brain abscess and one of the multiple abscesses were drained. All subdural/epidural empyemas were treated surgically. Antibiotics were administered intravenously for 13 to 22 days (mean 22 days). All patients underwent HBO therapy; the number of treatments ranged from 26 to 45 dives (mean 30). Treatments were given once daily at 2.2 atmosphere absolutes for 60 min at 12 m. During the hospital stay all improved their clinical condition, with continued regression of abnormalities on magnetic resonance imaging (MRI). In the following weeks, other interventions were performed to treat the origin of the infections. At 6 months follow-up they were all in good clinical condition, either symptom free or with minor residual symptoms. MRI at this time showed no evidence of disease in three, a residual dural enhancement in one and a residual shrunken collection in the child with multilocated abscesses. No recurrence was observed during a mean follow-up of 21 months (range from 7 to 72 months).Conclusion HBO therapy in children with brain abscesses seems to be safe and effective, even when they are associated with subdural or epidural empyemas. It provides a helpful adjuvant tool in the usual multimodal treatment of cerebral infections and may reduce the intravenous course of antibiotics and, consequently, the duration of hospitalization. Multidisciplinary management is recommended to optimize care for these critically ill children.     

Brucellar spinal epidural abscess of cervical location: report of four cases

Spinal epidural abscesses account for 1 or 2 of every 10,000 hospital admissions, Staphylococcus aureus being the bacterium most frequently involved. Brucellosis is a disorder of worldwide distribution, relatively frequent in South America and in Mediterranean countries in Europe and Africa. Whilst in the USA only 200 cases are reported every year, in Spain it is the most frequent zoonosis. This systemic disease seldom produces spondylodiscitis which in a minority of cases may be complicated by spinal epidural abscesses, in general of lumbar location. The purpose of this article is to analyse 4 cases of brucellar spinal epidural abscess of cervical location and diagnosed in the Province of Teruel, Spain, an endemic area for the disease, through 10 consecutive years (1990-1999). We consider noteworthy the following facts: the first case was a technical employee who acquired the infection in our laboratory of microbiology, the second presented with an extensive purulent collection invading prevertebral and retropharyngeal regions, the third case was cured only with antibiotics without residual deficits. In the fourth case we were not able to demonstrate spondylodiscitis accompanying the epidural abscess at the C2-C6 levels. We discuss especially the epidemiological aspects of brucellosis, the existence of epidural abscess without spondylodiscitis, the clinical manifestations, the diagnosis by means of magnetic resonance imaging, specific serological tests for Brucella, antibiotic treatment and the prognosis of our cases.     

Endoscopic management of brain abscesses

Background: Treatment of brain abscess is still a subject of controversy. Simple therapeutic approaches like twist drill/burr hole aspiration with or without insertion of a drain are also quite effective. There are reports of encouraging results following endoscopic treatment. We are reporting our results of endoscopic approach on 24 patients. Materials and Methods: This is a prospective study on 24 patients of brain abscesses treated between January 2004 and January 2007. All the cases except those with small abscesses (less than 1.0 cm in diameter) and multiloculated abscesses were included. Gabb 6-degree rigid endoscope was used. Repeat CT scan was done in all cases within 7 and 30 days after surgery. Ten patients (42%) had small residual abscess on 7 th post-operative day's CT scan, while 30 th post-operative day's CT scan did not show any significant lesion in all the cases. Results: There were 23 patients of chronic otitis media and one of congenital cyanotic heart disease. Glasgow coma score (GCS) was 3 in one patient, 13 in two cases, 14-15 in 21 cases. There were 14 cerebellar, 8 temporal and 1 frontal and thalamic abscess each. All the patients recovered completely except one who died (GCS 3). There was no procedure-related complication. Hospital stay ranged from 7 to 12 days with an average of 8.2 days. Follow-up ranged between 6 and 42 months. Conclusion: Endoscopic aspiration of brain abscess appears to be a safe and effective alternative method of treatment. There is direct visualization of abscess cavity, completeness of aspiration can be assessed, and perioperative bleeding can be controlled.     

Diagnosis and management of spinal epidural abscess.

Twenty-five patients with spinal epidural abscess were treated at the University of Western Ontario hospitals between July 1980 and July 1990. There were eighteen males (72%) and seven females (28%), with a median age of 60 years. Concurrent illness resulting in immunocompromise was present in 60%. Eleven presented with complete myelopathy, thirteen had limb weakness, and one had no neurological deficit. In twenty cases the abscess consisted of frankly purulent material, while in five the epidural collection consisted of chronic granulation tissue. Staphylococcus aureus was isolated in 64% of the abscesses. Twenty-seven surgical procedures were performed on 21 patients. Ten cases occurred in the cervical spine (40%), seven in the thoracic spine (28%), three in both the cervical and thoracic spine (12%) and five in the lumbosacral spine (20%). Fourteen patients (56%) retained or recovered ambulation and there were five deaths (20%). The progression from back and radicular pain to weakness and eventual paralysis continues to be characteristic of spinal epidural infection. Morbidity and mortality remain unacceptably high because of delay in diagnosis and treatment. Magnetic resonance imaging is the radiological investigation of choice for the diagnosis of spinal epidural abscess. Prompt intervention, before the development of severe neurological deficits, can improve outcome. Immediate surgical drainage combined with antibiotics remains the treatment of choice.     

Spinal epidural abscess Report of two cases

The case histories of two patients with an acute spinal epidural abscess are reported. When presented with a patient suffering from a spinal cord syndrome, the physician must keep in mind the possibility of a spinal epidural abscess. A rapid diagnostic procedure, prompt laminectomy, and medical treatment are particularly essential to total recovery in such cases.     

Brucellar spinal epidural abscess

Spinal epidural abscesses account for approximately one of every 10, 000 admissions to tertiary hospitals. The midthoracic vertebrae are the most frequently affected, whilst the cervical spine is involved in fewer patients. Staphylococcus aureus is identified as the cause in most cases of epidural abscess; other bacteria responsible include Gram-negative bacteria, Streptococcus species and Brucella species. We report the case of a patient with cervical spondylodiscitis at level C4-C5 and an epidural abscess which was compressing the spinal cord and the retropharyngeal space. The previous symptoms of brucellosis were atypical. We discuss the clinical manifestations, diagnosis, treatment and prognosis of the case.     

A less invasive posterior approach for the management of extended secondary epidural abscess technical note

Spondylodiscitis is considered to be the main cause of epidural abscess. In this report, the authors present their concept for the management of the extended epidural abscess that occurs in combination with spondylodiscitis. It consists of debridement and fusion for spondylodiscitis together with epidural abscess drainage using a microscopically assisted percutaneous technique. In the period from April 2000 to April 2004, 5 patients with spondylodiscitis and an accompanying extended epidural abscess were operated on. The mean age of the patients was 66 years. There were 4 males and one female. The follow-up period ranged from 3-12 months. To manage the extended epidural abscess, the authors created one or two drainage sites along the extension of epidural abscess. These drainage sites were made using a microscopically assisted percutaneous approach. In all presented cases, the offending organism was Staphylococcus aureus. The postoperative infection markers showed marked regression. The postoperative control MRI demonstrated effective drainage of the extended epidural abscess. Regarding the neurological deficits, 3 patients previously classified as Frankel C showed an improvement to Frankel E within 3 months postoperatively. From these results, it seems that our technique (ventro-dorsal abscess drainage combined with a microscopically assisted percutaneous approach) could be a successful method for the management of the extended epidural abscess associated with spondylodiscitis.     

Extensive spinal epidural abscess as a complication of Crohn’s disease

A spinal epidural abscess is a neurosurgical emergency. Successful treatment frequently requires decompression of the spinal canal in combination with intravenous antibiotics. We report a patient with Crohn’s disease who developed an extensive spinal epidural abscess communicating with an intra-abdominal collection.     

Cervical epidural abscess

We present 3 new cases of cervical epidural abscess (CEA), a rare condition, along with a review of 12 other case reports. The average patient age was 45 years; just over half were male. The abscesses usually involved the mid to lower cervical region and extended an average of three to four segments. Neck stiffness was present in all patients; root pain and paresthesias were present less often. Weakness of one to four extremities developed in all but one patient. Sensory levels were frequently present, sometimes below the site of the lesion. All but two patients were febrile. All but two had elevated CSF protein, and all but two had a pleocytosis; myelography always revealed a complete or partial block. Staphylococcus aureus was the causative organism in 8 of 11 patients. CEA should be considered in a patient with neck stiffness, paresthesias, and/or radicular pain so that CT or myelography followed by surgical decompression and/or antimicrobial drugs can be initiated before prolonged weakness develops. One of our patients developed a syrinx causing a new neurologic deficit 3 years after treatment. Delayed syringomyelia, a rare complication of extramedullary lesions, lends support to vascular occlusion as the major mechanism of damage in epidural abscess.     

Spinal epidural abscess complicating chronic epidural analgesia in 11 cancer patients: clinical findings and magnetic resonance imaging

We reviewed the records of all patients who had received an epidural catheter for management of chronic cancer pain in a 3-year period (1993–1996). Patients with nervous system infections were identified, and pertinent clinical, radiological (magnetic resonance imaging), and bacteriological data were analyzed. We identified 11 patients who developed spinal epidural abscess (SEA). All of these had back pain; radicular signs occurred in seven patients and spinal cord compression in two patients. Magnetic resonance imaging revealed SEA in all 11 patients. SEA was iso- to hypointense on T1-weighted images and hyperintense on T2-weighted images relative to spinal cord. After gadolinium administration seven lesions showed characteristic rim enhancement while three showed minimal enhancement. No signs of diskitis or osteomyelitis were present, and the abscess was always localized to the posterior epidural space. Cultures were positive in all cases and revealed Staphylococcus epidermidis in eight and S. aureus in three. All patients were treated with intravenous antibiotics, and four had an additional decompressive laminectomy. Two patients died within 1 week of diagnosis from overwhelming septicemia despite apparently adequate antibiotic treatment. Within 4 weeks after diagnosis of SEA two patients died from widely metastatic disease, although infection may have contributed. One patient developed septicemia while receiving appropriate antibiotics and underwent emergency laminectomy. The neurological deficits recovered in all patients who survived the acute infectious episode. We conclude that patients with chronic epidural catheters for cancer pain require prompt neurological evaluation and magnetic resonance imaging when SEA is suspected. Early evaluation and treatment may lead to full recovery. Received: 21 December 1998 Received in revised form: 23 February 1999 Accepted: 3 March 1999     

中枢神经系统类鼻疽病的临床特点分析

目的 分析中枢神经系统类鼻疽病的临床特点，以指导临床诊治。方法 回顾性分析2014年1月至2018年12月收治的12例中枢神经系统类鼻疽病的临床资料，总结临床特点。结果 12例中，10例为农民；8例有2型糖尿病病史。12例均有高热，静脉血中性粒细胞百分比、C反应蛋白、降钙素原升高。10例合并有肺部受累。12例中，脑脓肿4例，硬脑膜下脓肿2例，急性脑脊髓膜炎6例；12例在培养分离出类鼻疽伯克霍尔德菌前均未能确诊。手术清除颅内局限性病灶为有效治疗方法。碳青霉烯类为有效抗生素。确诊后6个月随访:死亡4例，其中急性脑脊髓膜炎3例，脑脓肿1例；6例遗留功能障碍；仅2例硬膜下脓肿完全康复。结论 中枢神经系统类鼻疽病病情凶险，极易误诊，预后差。早期诊断、及时有效缓解颅内压增高、尽早足量应用敏感抗生素，以及控制好基础疾病是治疗成功的关键     

Epidural spinal infection in intravenous drug abusers

The incidence of spinal epidural abscess and disk space infection appears to be rising in intravenous drug-using patients. We report 18 cases seen over three years in two municipal hospitals. Staphylococcus aureus was the most common infective agent, but two patients had Mycobacterium tuberculosis infection. Computed tomography of the spine facilitates diagnosis. Early treatment improves outcome but host factors play a role in recovery.     

Cyanotic congenital heart disease with suspected stroke. Should all patients receive antibiotics?

Two patients with cyanotic congenital heart disease (CHD) and erythremia were seen for abrupt onset of focal neurologic deficits and/or seizure without signs of infection or increased intracranial pressure. Clinical features and initial computed tomography (CT) in both cases suggested stroke. Subsequent CT scans demonstrated cerebral abscess, proved at operation. Review of records of patients with CHD at the University of Rochester (NY) Medical Center from 1965 to 1981 disclosed 12 cases with brain abscess but only two cases with aseptic cerebral infarction. All but one patient with abscess were cyanotic. One third of patients with abscess had a clinical picture suggesting stroke. Clinical or radiologic features of half the cases indicated that cerebral infarction may have led to abscess formation. Diagnosis of brain abscess and immediate antibiotic therapy should be strongly considered in patients with cyanotic CHD who suffer a suspected cerebral infarction.     

Update in the diagnosis and management of central nervous system infections

Central nervous system (CNS) infections presenting to the emergency room include meningitis, encephalitis, brain and spinal epidural abscess, subdural empyema, and ventriculitis. These conditions often require admission to an intensive care unit (ICU) and are complications of ICU patients with neurologic injury, contributing significantly to morbidity and mortality. Reducing morbidity and mortality is critically dependent on rapid diagnosis and, perhaps more importantly, on the timely initiation of appropriate antimicrobial therapy. New insights into the role of inflammation and the immune response in CNS infections have contributed to development of new diagnostic strategies using markers of inflammation, and to the study of agents with focused immunomodulatory activity, which may lead to further adjunctive therapy in human disease.     

Multiple spinal epidural metastases; an unexpectedly frequent finding.

In a prospective study, patients with known malignant disease who were suspected of having a spinal epidural metastasis, had myelography which was not confined to the clinically suspected site, but included at least the whole lumbar and thoracic spinal canal. Fifty four of the 106 myelograms revealed at least one epidural metastasis. Twelve of these 54 myelograms showed two separate lesions, and four myelograms showed three separate lesions. In all 16 cases with multiple lesions at least one of the lesions was asymptomatic at the time of the diagnosis. It is concluded that multiple spinal epidural metastases are of common occurrence and occur in about one third of the cases. This finding may have important clinical implications. Examination of the spinal canal for epidural metastases should not be confined to the clinically suspected site, but should include as extensive an area as possible of the spinal canal, whatever technique is to be used.     

Nonsurgically treated cervical brucellar epidural abscess causing spinal cord compression

Cervical spinal cord compression due to brucellar epidural abscess is extremely rare, with only 13 previously reported cases. We present another case of cervical spinal epidural abscess causing spinal cord compression. Diagnostic tools and treatment options are discussed.     

Computed tomography (CT) in the diagnosis of intracranial abscesses. Brain abscess, subdural empyema, and epidural empyema

Nine cases of brain abscess, five of subdural empyema, and one of epidural empyema with associated subdural empyema were identified using computed tomography (CT). Smal and multiple abscesses as well as unilateral, bilateral, and parafalcine empyemas were detected. These lesions were demonstrated rapidly and accurately, even in areas that are demonstrated poorly by other diagnostic techniques. No false-negative studies were found in cases of brain abscess or subdural empyema. However, since the appearance of brain abscesses of CT scans is similar to that of neoplastic and vascular lesions, false-positive reports of brain abscess were encountered.     

Spinal epidural abscess. Early detection with gadolinium magnetic resonance imaging.

To emphasize the importance of timely diagnosis of spinal epidural abscess, thirteen patients admitted to a single general hospital are presented. In 10 patients, diagnosis was not appreciated at the time of presentation. After treatment, four remained paraparetic and three died. Nine patients had predisposing factors, including seven with infections at sites other than the spinal canal. Staphylococcus aureus was the predominant organism. Outcome was equally devastating for the seven patients with acute and the six patients with chronic infections. Gadolinium-enhanced magnetic resonance imaging was the most useful diagnostic test, and we recommend that it be performed promptly in any patient with clinical features suggesting spinal epidural abscess since early surgical drainage and appropriate antibiotics may yield a favorable outcome.