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Indian Pediatr 2011;48: 973-974 |
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Intramedullary Spinal Cord Abscess
Masquerading as Spinal Tumor |
*Mukul Aggarwal, KC Aggarwal, *Karamchand and #Archana
Aggarwal
From the Departments of Pediatrics, *Neurosurgery and
#Radiology, VMMC and Safdarjung Hospital, New Delhi, India.
Correspondence to: Dr KC Aggarwal, Consultant in
Pediatrics, VMMC and Safdarjung Hospital, New Delhi 110 029.
Email: [email protected]
Received: September 21, 2009;
Initial review: January 22, 2010;
Accepted: August 06, 2010.
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We report a 5-year-old girl who presented with acute onset paraparesis
with differential loss of sensation. Magnetic resonance imaging of
spine revealed exophytic intramedullary mass lesion from T12 to L1.
Peroperatively, the diagnosis was confirmed as abscess. The patient
recovered following decompression and antibiotic treatment.
Key words: Dissociative anesthesia, Intramedullary abscess,
Paraparesis.
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Though spinal abscesses, especially acute
epidural abscess or following caries spine are seen occasionally in
pediatric population, intramedullary abscesses are seen very rarely
[1-5]. We report a 5-year-old girl who presented as acute
paraparesis without significant pyrexia or vertebral anomaly.
Contrast enhanced MRI suggested a spinal cord tumor, which on
surgery was detected to be an abscess.
Case Report
A 5-year-old developmentally normal girl who
presented with pain in lower abdomen for 7 days, followed by
progressive weakness of both lower limbs and increased frequency of
micturition of 5 days duration. Parents noticed decreased sensations
in lower limbs. There are no history in recent past suggestive of
any infections or treatment. On examination, the patient showed no
spinal deformity or dermal sinus. Neurological examination revealed
a cooperative child with normal higher functions. Cerebellar signs
and signs of meningeal irritation were negative. Fundus exam was
normal. Motor examination revealed hypotonia in lower limbs, power
was 3/5 in dorsiflexion at both ankle and 4/5 in flexion and
extension at both knee joints. Deep tendon reflexes were normally
elicitable. Babinski reflex was bilaterally positive. There was
differential loss of pain and temperature upto inguinal ligament in
both lower limbs but vibration and position sense were preserved.
There was no sacral anesthesia and anal reflex was elicitable.
Investigations showed normal chest and dorsolumbar spine X-rays,
urinalysis and CSF examination. Mantoux test was negative and the
ESR was 22 mm in first hour.
MRI spine revealed well defined circumscribed
partially exophytic intramedullary mass measuring 1.7 cm at D12- L1
level, which was hypointense on T1 weighted images and hyperintense
on T2 weighted images with internal hemorrhage along with long
segment cord edema from C5 to L1 level. Contrast enhancement with
gadolinium showed scattered enhancement mainly at periphery,
suggestive of an astrocytoma or ependymoma.
Per-operatively, intramedullary abscess at D12
level was found, which was drained. Pus sent for gram
and AFB staining and culture revealed no growth. Subsequently, the
patient was treated with oral prednisolone, ceftriaxone, cloxacillin
and amikacin for 4 weeks. The patient showed marked improvement in
all symptoms within 2 weeks of surgery. At discharge, 4 weeks post
surgery, the patient was ambulatory with power of 4+ in both lower
limbs and return of bladder and bowel sensations. The diagnosis of
primary intramedullary spinal abscess was made.
Discussion
Intramedullary spinal cord abscess is rarely seen
in children with only 38 reports in children [1]. It occurs
more frequently in males with peak incidence in first and third
decades of life [2]. Solitary abscess is more common and seen mostly
in the thoracic cord. Abscesses are considered primary when no other
infection source can be found. Secondary abscesses (upto 85% cases)
arise from another infection site, either contiguous to cord (dermal
sinus or neural tube defect) or distant (most commonly from lung)
[1, 3]. They are also classified
as acute (<1 week), sub-acute (1- 6 weeks) or chronic
(>6 weeks) [2]. Our case did not show a congenital malformation of
the spine and clinical features were of insidious onset, suggestive
of sub-acute primary solitary abscess. Organisms isolated include
Staphylococcus [4] and Mycobacterium tuberculosis [5].
However, 25-40% abscesses are sterile on culture, as in our case
[4].
In an acute presentation, symptoms of infection (e.g.
fever, backache, malaise) are common. Chronic cases might mimic
features of intramedullary tumor and show neurological symptoms [6].
The procedure of choice for diagnosis of intramedullary spinal
abscess is gadolinium-enhanced MRI that shows rim enhancement of its
margins. Spinal cord abscesses produce homogenous enlargement on
T1-weighted images and hyperintensity on T2-weighted images [4].
These findings may be seen in intramedullary
tumors as well.
Treatment of intramedullary abscesses involves
surgical drainage and appropriate antibiotics. Steroids are used to
reduce spinal cord swelling and associated edema [7]. Paradoxical
increase in size of lesion may occur necessitating surgical
intervention [8].
Approximately 70% of patients may have residual
neurological sequelae [9]. Some patients may show paraplegia due to
recurrent or non-resolving abscess and infarct due to vascular
occlusion and inflammation.
Contributors: MA and KCA, managed the case
and drafted the manuscript. KCA shall act as the guarantor. AA
interpreted radiological investigations. Karamchand operated upon
case.
Funding: None.
Competing interest: None stated.
References
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Intramedullary epidermoid associated with an intramedullary spinal
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Spinal cord infection: myelitis and abscess formation. AJNR AM J
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1994;35:327-30.
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