Portal de Periódicos da CAPES

A CASE OF A CERVICOSACRAL EPIDURAL ABSCESS COMPLICATED WITH MULTI-LEVEL PNEUMORRHACHIS

2023; Elsevier BV; Volume: 164; Issue: 4 Linguagem: Inglês

10.1016/j.chest.2023.07.1533

1931-3543

OSCAR HINOJOSA, JEFFREY SONG, OMAR AMMARI, J. Fontana,

Pelvic and Acetabular Injuries

INTRODUCTION: Pneumorrhachis or spinal pneumatosis, is defined as the presence of air in the spinal canal.It is a rare radiographic finding usually occurring in traumatic injuries.It rarely occurs in the context of non-traumatic or surgical patients due to infectious etiology.We report a case of atraumatic pneumorrhachis from a polymicrobial infection in the setting of a decubitus ulcer. CASE PRESENTATION:We present the case of a 38-year-old male patient with a past medical history of hemorrhagic stroke as a child resulting in significant immobility.One month prior to admission the patient developed worsening chronic back pain, progressive weakness, and a rapidly enlarging sacral ulcerHe presented with altered mentation, fevers, and signs of septic shock.The physical exam revealed a stage IV sacral ulcer with abundant purulent secretion and bone exposure.The laboratory findings were significant for leukocytosis (39K/uL) and elevated inflammatory markers, while the remainder was unrevealing.On further investigation, a chest CT revealed bilateral ground glass opacities and pneumorrachis affecting the thoracic spine.The spinal MRI revealed an epidural circumferential collection that extended from C1 to the sacrum consistent with an extensive epidural abscess complicated with multi-level pneumorrhachis resulting in several areas of spinal canal stenosis.The abscess communicated with the sacral ulcer and an accessory gluteal abscess.Blood cultures were polymicrobial, including Streptococcus anginosus, Escherichia coli, and Proteus mirabilis.The patient was intubated for airway protection, initiated on broad-spectrum antibiotics, fluid resuscitation, and vasopressor support with progressive improvement.Unfortunately, due to abscess extent, poor functional status, and anticipated poor surgical wound recovery the patient was not offered spinal surgical intervention.Therefore, the mainstay of treatment was prolonged antimicrobial therapy DISCUSSION: The presence of intraspinal air, pneumorrhachis, is clinically rare, but it has been previously described in cases of trauma [1], pneumothoraces [2], and iatrogenesis [3].In these cases, pneumorrhachis was incidental, innocuous, and self-limited.Regarding its physiopathology, it usually arises from direct intraspinal air entry as in the case of penetrating spine injuries [4] or through pressurized dissection of fascial planes from the posterior mediastinum through the neural foramina into the epidural space [5].Kapur et.al. described a case of a dural-enteric fistula from a gunshot wound [6].On CT, intraspinal gas cannot be clearly differentiated from intraspinal air and they may coexist [4].This is likely the case of our patient, where the pneumorrhachis was probably the result of the communicating sacral ulcer and the extensive epidural infection by gas-forming bacteria, which are similarly reported in other cases [7, 8].To our knowledge, only 2 cases of pneumorrhachis associated with sacral ulcers have been reported, but none associated with such an extensive epidural abscess [9, 10]. CONCLUSIONS:The differential diagnosis of pneumorrhachis should be expanded beyond the usual traumatic or iatrogenic etiologies and include infectious sources in the appropriate clinical context.This case report challenges the classically described self-limited course of pneumorrhachis that is well-established in the literature and remains an uncommon, life-threatening source of septic shock.