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Título

Cervical Infectious Spondylodiscitis as a differential diagnosis of acute flaccid tetraparesis

RESUMO

Case Presentation: A 72-years-old man, previously hypertensive and alcoholic, presented to the emergency room with a five-day history of shortness of breath, cough, fever, muscle pain and four limbs weakness. Neurological examination demonstrated tetraparesis, hypotonia in four limbs, areflexia in upper limbs and hyporeflexia in lower limbs. Laboratory demonstrated leukocytosis. Blood culture was positive for methicillin-sensitive SA. Cerebral spinal fluid analysis revealed important protein elevation, no glucose consummation and cell count within reference range. At arrival of patient, the MRI was not available, and among the differential diagnosis, the main hypothesis was of Guillian-Barré syndrome. Extended investigation with cervical MRI realized as soon as available, showed at FLAIR and T2, inflammatory hypersignal at C3-C4 left facet joint and three isolated collections. The third formation was causing vertebral foramen stenosis with hypersignal alterations at the adjacent spinal cord compatible with compressive myelopathy. All three formations were suggestive of abscess, due bacterial spondylodiscitis. The patient was treated with intravenous oxacillin, with clinical improvement and regression of the masses at a posterior control MRI.
Discussion: Spondylodiscitis refers to the infectious process that affects the vertebral body, the posterior vertebral arch, and the intervertebral disc. Installed in an insidious way and has a slow evolution, usually manifesting as fever, local pain, changes in sensitivity and strength in limbs, and may present as a radiculopathy as well as a spinal syndrome due to the involvement of the spinal canal. The physical examination of uncooperative patients can make it difficult to discriminate sensitivity changes such as, for example, sensory level in the context of spinal cord syndrome. In this context of flaccid tetraparesis, as in the case above, the acute demyelinating polyradiculopathy syndrome is an important differential diagnosis. This protein-cellular dissociation in the cerebrospinal fluid, uncommon in peri-medullary infections that usually progress with an increased number of cells in the CSF, was notorious confounding factor, alongside to the limb flaccid paresis found in the acute spinal cord injury.
Final comments: The acute flaccid tetraparesis has a large number of differential diagnoses ang usually demands early complementary exams to the correct evaluation of the lesion, especially in the ER.

Palavras Chave

Flaccid tetraparesis, Spondylodiscitis, Compressive myelopathy

Área

Neuroinfecção