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Título

HOLOCORD SPINAL EPIDURAL ABSCESS – A RARE CASE REPORT

RESUMO

CASE REPORT: male healthy patient, 56 years old, refers back pain started 9 days ago irradiated to lower limbs and perineum with urinary hesitancy and vomit without fever. First diagnosis thought was nephrolithiasis, excluded after normal abdomen computed tomography (CT). The following day, started with weakness in the right lower limb (mainly in quadriceps), constipation and urinary retention. CT of the thoracic and lumbar region was normal. After two days patient evolved with somnolence, flaccid paraplegia, absence of deep sensitivity on lower limbs, peripheral facial palsy in the right, dysautonomia and anisocoria. Cerebrospinal fluid showed pleocytosis (neutrophil and lymphocyte predominance), hyperproteinorraquia and important glucose consumption with lactate level of 9.9. Magnetic resonance evidenced anomalous leptomeningeal enhancement of the cerebellum and skull base cisterns; thickening and anomalous enhancement of the arachnoid and diffusely involving the entire spinal cord, including cauda equina; laminar collection with peripheral contrast enhancement extensive on the epidural posterior region from T1 to L2 with greater thickness in the lumbar. We started empirical treatment with ceftriaxone and meropenem plus dexamethasone 4 mg every six hour. Neurosurgery team indicated conservative management. Serologies for HIV, syphilis and hepatitis and PCR for M. tuberculosis in CSF were negative. All CSF and blood cultures (bacteria, fungi and mycobacterium) were negative. On the next day, patient worsened consciousness level requiring orotracheal intubation. After eight days of antibiotic CSF had a significant improvement. We treated the patient during forty days, with mild neurological improvement in consciousness level and quadriplegia sequelae. During hospitalization patient presented many complications (secondary bacterial infections, acute renal failure and upper gastrointestinal bleeding) progressing to death 44 days after hospital admission. DISCUSSION: Until now less than twenty cases of holocord spinal epidural abscess (SEA) had been published and it is more common in immunocompromised. The commonly symptoms are fever, back pain and neurological deficit and the mortality rate is about 15%. Here we present an immunocompetent man that had a bad evolution. FINAL COMMENTS: SEA can mimic other medical conditions, but have a high morbidity and mortality, so it is essential to be attentive to avoid delaying diagnosis and treatment.

Palavras Chave

Spinal Epidural Abscess; immunocompetent;