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Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India, jeet1516{at}gmail.com
To the Editor:
A 2-yr-old-child presented to the emergency department in a peripheral hospital with fever, irritability, and vomiting. Blood, stool, and urine cultures were obtained. We performed lumbar puncture through the L3–4 space and sent cerebrospinal fluid for microscopy and culture. The number of attempts and type of spinal needle were not recorded. All cultures were normal. The child was empirically started on antibiotics, improved, and was discharged.
Two weeks later the child presented to our emergency department with redness and swelling at the site of lumbar puncture (Fig. 1), along with fever and inability to move the left lower limb. Contrast magnetic resonance imaging (MRI) scan demonstrated 2 x 1.8 x 1.8 cm3 area of altered signal in the posterior epidural space opposite the L4–5 vertebra, hypointense on T1 and hyperintense on T2-weighted images, with peripheral rim enhancement after contrast administration (Fig. 2). The diagnosis was an epidural abscess at the L4–5 vertebra. Immediate neurosurgical intervention under general anesthesia revealed an infected epidural dermoid. The infected dermoid was removed, and the child awakened from anesthesia. Cultures drawn during surgery were positive for Proteus mirabilis. The child was treated with antibiotics, with resolution of the fever, but the lower limb deficit persisted.
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Spinal epidural abscesses in children require immediate diagnosis and treatment to prevent morbidity and mortality (1). Spinal cord tumors in children account for less than one-fifth of central nervous system tumors (2), and only 3% are epidermal in nature (3). Spinal epidural abscesses are rare in infants and children (4,5). Hematological spread of the causative agent from a distant site is the primary etiological factor. Epidural anesthesia and lumbar puncture are known risk factors for spinal epidural abscess (6,7).
A diagnosis of epidural abscess in preverbal children is challenging, as initial signs are nonspecific and focal findings such as tenderness may be absent. The resulting delay in diagnosis increases the likelihood of permanent neurological deficit (5). Once epidural abscess is suspected, evaluation and treatment must follow emergently. MRI is the diagnostic tool of choice. Staphylococcus aureus, Streptococcus, and a variety of Gram-negative bacilli are likely pathogens (8). Laminectomy, surgical decompression, and irrigation of the abscess cavity plus systemic antibiotics for 4–8 wk after drainage is traditional treatment for spinal epidural abscess.
REFERENCES
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