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0INTRAMEDULLARY SPINAL CORD ABSCESS IN COMBINATION WITH NEOPLASMS (CASE REPORT)
Khalikulov E.Sh.
Tashkent Pediatric Medical Institute https://doi.org/10.5281/zenodo.13123740
Abstract. In this article a case of intramedullary abscess in a 4-year-old girl is presented. Based on the anamnesis, clinical, neurological and instrumental studies, a diagnosis was established and surgical intervention was performed. In the postoperative period, a spinal cord neoplasm was detected against the background of an abscess based on histological examination. Antibiotic treatment was started, but disease progression led to a fatal outcome.
Keywords: intramedullary spinal cord abscess (IASC); spinal cord tumor; laminectomy.
Relevance. It is important to suggest that intramedullary spinal cord abscess (IASCA) is a rare infectious pathology of the central part of the spinal cord. The first report about a patient with IASCA was made in 1830 by Hart [1,2]. To date, according to the literature, about 140 cases of IASCA have been described [3]. According to researchers, 36% of intramedullary abscesses affect the cervical region, 36% - the spinal cord cluster and 29% - the thoracic region of the spinal cord [4]. According to the latest data, only 8% of IASCA cases arise from the hematogenous route. In other cases, the source remains unknown [2,5].
Although spinal abscesses, especially acute epidural after osteomyelitis, are sometimes observed in pediatric practice, intramedullary abscesses are rare [6]. Predisposing factors include dermal sinus, epidermoid cysts, previous infections, iatrogenic complications, and trauma [3,7]. There was presented a case of a 5-year-old girl with lower paraparesis and signs of fever. Magnetic resonance imaging (MRI) revealed a spinal cord abscess. Postoperatively, histological data revealed a concomitant intramedullary neoplasm.
Clinical case. A 4-year-old girl was admitted to the infectious diseases clinic with a body temperature of 380 C and higher, headaches. A lumbar puncture was performed, where purulent fluid was obtained. With a diagnosis of "meningoencephalitis", antibacterial therapy with broad-spectrum antibiotics was started. During the therapy, the patient developed lower paraplegia with urinary and stool retention. A series of MRI images (Fig. 1) revealed an intramedullary lesion from T6 to T8, which intensified with contrast.
Fig. 1. Intramedullary abscess before surgery.
The disease progressed to tetraparesis over time. Two weeks after the onset of the disease, the patient was transferred to the neurosurgery department and laminectomy with drainage of the intramedullary abscess was performed. The results of collecting material for histology established the diagnosis of anaplastic astrocytoma of the spinal cord (Fig. 2).
Fig. 2. Histologically there is an astrocytoma The patient's condition did not improve dynamically. Repeated MRI examination revealed spinal cord edema and expansion of the ischemic zone (Fig. 3).
Fig. 3. MR images of the spinal cord after surgery.
In the postoperative period, on the 8th day, the patient had impaired consciousness, increased body temperature with impaired cardiovascular and respiratory activity and death.
Analysis of the results. In this article, there was presented the results of diagnosis and treatment of a patient with lower paraparesis caused by an abscess of the thoracic spinal cord. The diagnosis was established based on the anamnesis, laboratory data and MRI studies. Spinal cord abscess is usually hyperintense in T2-weighted studies with lesions extending to the periependymal areas [8]. MRI with contrast is the gold standard for accurately determining the location and extent of an abscess, as well as identifying any predisposing structural spinal cord abnormalities [9].
Abscesses are considered primary when no other source of infection can be found. Secondary abscesses (up to 85% of cases) arise from another site of infection by contact (skin defect of the sinus or neural tube) or at a distance (usually hematogenously from the lungs) [10,11].
Conclusion. It should be suggested that they are also classified as acute (less than 1 week), subacute (1-6 weeks), or chronic (more than 6 weeks) [12]. In our case, no congenital malformation of the spine was identified and the clinical features were insidious in onset, indicating a subacute primary solitary abscess. Isolated organisms include Staphylococcus aureus [13] and Mycobacterium tuberculosis [14]. However, 25-40% of abscesses are sterile on culture, as in our case [13,14].
In the acute form of the disease, symptoms of infection (eg, fever, back pain, malaise) are common. In chronic cases, it may mimic an intramedullary tumor and neurologic symptoms may be observed [15].
The procedure of choice for the diagnosis of intramedullary spinal abscess is contrast-enhanced MRI, which shows enhancement of the margins of the lesion. Spinal cord abscesses show homogeneous enhancement on T1-weighted images [13].
Surgical treatment of intramedullary abscesses includes drainage and appropriate antibiotics. Steroids may be used to reduce spinal cord swelling [16]. Some patients may present with paraplegia due to recurrent or non-resolving abscess and infarction due to vascular occlusion and inflammation [17].
Approximately 70% of patients may have residual neurological impairment [18]. Some patients may present with paraplegia due to recurrent or non-resolving abscess and infarction due to vascular occlusion and inflammation.
By summarizing it can be concluded that the presented a literature review was performed using the PubMED database. Cases of a combination of spinal cord neoplasm and intramedullary abscess described in different references are extremely rare [19]. Spinal cord neoplasm was not diagnosed due to the absence of clinical manifestation. Unfortunately, for technical reasons, it was not possible to perform an immunohistochemical study. It means this analysis would have supported our arguments and their validity.
REFERENCES
1. Iwasaki, M.; Yano, S.; Aoyama, T.; Hida, K.; Iwasaki, Y. Acute onset intramedullary spinal cord abscess with spinal artery occlusion: A case report and review. Eur. Spine J. 2011, 20, Pp.294-301.
2. Chan, C.T.; Gold, W.L. Intramedullary abscess of the spinal cord in the antibiotic era: Clinical features, microbial etiologies, trends in pathogenesis, and outcomes. Clin. Infect. Dis. 1998, 27, Pp. 619-626.
3. Szmyd, B.; Jabbar, R.; Lusa, W.; Karuga, F.F.; Pawelczyk, A.; Blaszczyk, M.; Jankowski, J.; Solek, J.; Wysiadecki, G.; Tubbs, R.S.; et al. What Is Currently Known about Intramedullary Spinal Cord Abscess among Children? A Concise Review. J. Clin. Med. 2022, 11, Pp.4549.
4. Byrne, R.W.; Von Roenn, K.A.; Whisler, W.W. Intramedullary abscess: A report of two cases and a review of the literature. Neurosurgery 1994, 35, Pp.321-326.
5. Rogers, A.P.; Lerner, A.; Metting, S.; Sahai-Srivastava, S. Cervical intramedullary spinal cord abscess: A case report. Radiol. Infect. Dis. 2017, 4,Pp. 113-116.
6. Garg RK, Malhotra HS, Gupta R. Spinal cord involvement in tuberculous meningitis. Spinal Cord. 2015;53:649-57. [PubMed] [Google Scholar
7. Khalikulov E.Sh., Usmanhanov O.A., Bekov R.N. Dermal sinus complicated by widespread two-chamber intramedullary abscess (case report). Ukrainian Neurosurgical Journal. No. 4, 2012, Pp. 50-53.
8. Fanous A.A., Olszewski N.P., Lipinski L.I., Oju J., Fabiano A.J., Idiopatic transverse myelitis mimicking an intramedullary spinal cord tumor. Case rep Pathol 2016:2016:8706062
9. Kalia V., Vibhuti; Aggarval T. Holocord intramedullary abscess. Indian J. Pediatr. 2007, 74, Pp. 589-591
10. Ditillio MV, Intramedullary spinal cord abscess: case report with review of 53 previously described cases. Surg Neurol. 1997; 7; Pp.351
11. Benzyl D., Epstein MH., Knuckey NW. Intramedullary epidermoid associated with an intramedullary spinal abscess secondary to a dermal sinus. Neurosurgery. 1992; 30: Pp. 118
12. Menezes AH, Graf CJ, Perret GE. Spinal cord abscess: review. Surgical Neurology. 1977;8: Pp.461.
13. Murphy KJ, Brunberg JA, Quit DJ, Kazanjian PH. Spinal cord infection: myelitis and abscess formation. AJNR AM J Neuroradiol. 1998;19: Pp. 341.
14. Hoda MF, Prasad R, Singh VP, Maurya P, Singh K, Sharma V. Spinal intramedullary tubercular abscess: a case report. Indian J Tuberc. 2005;52:Pp.211.
15. Guzel N, Eras M, Guzel DK. A child with spinal intramedullary abscess. Childs Nerv Syst. 2003;19;773-6.
16. Schroeder KA, Mckeever PE, Schaberg DR, Hoff JT. Effect of dexamethasone on experimental brain abscess. J Neurosurgery. 1987;66: Pp.264.
17. M.Aggarval, KC Aggarval, Karamchan and Archana Aggarval. Intramedullary spinal cord abscess masquerading as spinal tumor. Indian Pediatrics. 2011; Vol.48, Pp. 973-974
18. Kalia V, Vibhuti, Aggarwal T. Holocord intramedullary abscess: clinical brief. Indian J Pediatr. 2007;74:Pp.589.
19. Yeow Leng Tan1, Minghe Moses Koh2 Cervical neuromyelitis optica with thoracic ependymoma. Surgical neurology international. 2021, 12(396). DOI: 25259/SNI_677_2021
