Today Simon and Vivek presented a challenging case of a 61 yo man with a history of IVDU, T2DM who presented to the VA ER after being found down at home and presented in DKA and then subsequently found to have MSSA bacteremia complicated by renal and epidural abscesses. Epidural abscess was found following activation of a “code stroke” when the patient presented with new upper extremity weakness and a normal sensorium.
So much to talk about with this case, including a general approach to patients who are “found down” (thanks Amanda for walking us through a broad DDx involving cardiac, neuro, metabolic, ID organ systems) and a general workup in staph bacteremia (briefly repeating BCx to document clearance, line removal, TTE/TEE to look for endocarditis, ID consult and +/- advanced imaging to look for sources of infection).
Another important point is that epidural abscess is considered a neurosurgical emergency and with a new neuro deficit these patients should undergo emergent surgical drainage.
One question that did come up is CSF findings in patients with epidural abscesses. Interestingly, this patient had a normal LP at presentation which according to a review of 43 cases from Baltimore is not an uncommon occurrence! While the majority of patients with epidural abscess had an abnormal CSF, the results were non-specific and often did not fit the classic pattern seen with bacterial meningitis!
In this case series, 72% of patients presented with backache, 47% with radicular pain (as did this patient), 35% with extremity weakness, 23% with a sensory deficit, 30% with bowel or bladder dysfunction, and 21% with frank paralysis (as in this patient).
Lumbar > thoracic > cervical in terms of frequency in site.
Bacterial spinal epidural abscess. Review of 43 cases and literature survey.