Anterior spinal epidural abscess due to Salmonella typhi : a report of a rare case treated conservatively and review of

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LETTER TO THE EDITOR

Anterior spinal epidural abscess due to Salmonella typhi: a report of a rare case treated conservatively and review of the literature Antonio Nardone • Federico Caporlingua Gennaro Lapadula • Antonio Santoro



Received: 10 November 2012 / Accepted: 15 March 2013 Ó Springer-Verlag Italia 2013

Keywords Epidural abscess: spinal  Epidural abscess: therapy  Central nervous system infections  Perimeningeal infections

Dear Editor, Spinal epidural abscess (SEA) is a suppurative process located between the dura mater and the vertebral periosteum. Its incidence ranges between 0.2 and 2/100,000 hospital admissions [1] and is related to the routine use of spinal epidural anesthesia, drug abuse, immune-suppression, diabetes mellitus, alcoholism and to the aging of the general population [2, 3]. The responsible pathogens are mostly Gram-positive, especially Staphylococcus aureus [3–5]. Gram-negative SEA is related to drug abuse [6], is rarer [3–5] and is commonly due to Escherichia coli and Pseudomonas aeruginosa [3]. We report a rare case of SEA due to Salmonella typhi in an immuno-competent risk-free patient who did not undergo any spinal procedure. A 43-year-old man presented with fever, diarrhea and low back pain. At physical examination, there were no signs of skin infections. Neurological examination was negative. He had a previous negative medical history. Laboratory examination showed 10.2 9 109/l leukocytes, predominantly neutrophilic. Erythrocyte sedimentation rate (ESR) was 44.0 mm/h. C-reactive protein was 19.38 mg/ dl. A lumbosacral MRI showed an in-homogeneous L5–S2 lumbar process located in the anterior epidural space (Fig. 1). The lesion was hypointense in T1-weighted

A. Nardone  F. Caporlingua (&)  G. Lapadula  A. Santoro Department of Neurology and Psychiatry, Neurosurgery, ‘‘Sapienza’’ University of Rome, Rome, Italy e-mail: [email protected]

images, hyperintense in T2-weighted images and enhanced peripherically. Therefore, radiological diagnosis of epidural abscess was proposed. Three blood cultures were performed and ciprofloxacin 400 mg daily was administered. Two days after, all the blood cultures showed positive results for S. typhi. The bacterium was resistant to aminoglycosides and sensitive to penicillins, cephalosporins and carbapenems. Nevertheless, being the patient allergic to penicillins and cephalosporins, meropenem (MIC B 0.25) 2 g 9 3/day was added to the therapy. Moreover, he was checked for immunological diseases, but all the exams showed negative results. During the hospital stay, low back pain was progressively reduced. Twenty-seven days after, inflammatory parameters were negative. A lumbosacral MRI showed the disappearance of epidural lesion, which left only a linear and fable enhancement on the osteoligamentous structures. The patient was discharged in good clinical condition and continued to take ciprofloxacin 500 mg tablets daily for at least 5 weeks. Follow-up controls confirmed the stability of the clinico-radiological status. Outcome after SEA can b