(P64) Spinal Epidural Abcess Caused by Streptococcus Intermedius

Chief Complaint : Severe lower back pain and bilateral lower extremity weakness

History of Present Illness : Patient is a 58 year-old female with past medical history (PMH) of hypercholesterolemia and HTN ( hypertension) was brought to Emergency Department (ED) with two weeks worsening of back pain. Pain was located in her lower coccygeal area was associated with dark urine, lack of appetite. She then started to develop bilateral lower extremity weakness to the point that she needed to use a cane to walk around. She also reported tingling and shooting pain with radiation to her lower extremities. She then began to notice a pain in her neck, weakness in her arms, tingling and shooting pain with radiation down to her bilateral arms, as well as difficulty tilting her head up. Her symptoms were associated with nausea, lack of appetite but no vomit.
She denied any fever chills, chest pain, abdominal pain, cough, SOB, blurry vision, dizziness, and vertigo and trauma.

Pertinent Physical Exam: Vital signs on presentation were temperature 37.9 °C, heart rate 82 beat per minute, respiratory rate 18 per minute, blood pressure 148/81 mmHg, and oxygen saturation 98% on room air. On examination, she was sitting in the supine position. She appeared uncomfortable, was wincing intermittently with movement of her neck and arms. Any head movement caused radiating pain to her bilateral hips. Physical exam was limited due to the severe pain. Pt had more passive ROM than active due to severe pain. She had no sensory deficient. Pt was moving all extremities. Neuro exam was intact.

Pertinent Laboratory Data: Labs were as follows: 11.9 K/mm3 (reference: 4.5-11 K/mm3), creatine 1.08 mg/dl (reference: 0.6-1.30 mg/dl), blood urea nitrogen (BUN) 29 mg/dl (reference: 7-23 mg/dl), ferritin: 760 ng/mL [16.4-294.0]; D-Dimer 2.08 mcg/mL (reference: less than 0.5); prothrombin time (PT) 13.5 seconds (reference: 12.2-14.9 seconds); international normalized ratio (INR) 1.2 (reference: less than 1), partial thromboplastin time (PTT) 26. (reference: 21.3-35.1 seconds), fibrinogen 572 (523-572); lactate dehydrogenase (LDH) 381 U/L (reference: 140-271 U/L), C-reactive protein (CRP) 22.3 mg/L (reference: less than 10 mg/L), Erythrocyte sedimentation rate (ESR) 71 mg/L (reference: less than 10 mg/L), Troponin 0.060 ng/mL (reference 0-0.034)

Case Discussion: Spinal epidural abscess (SEA) is a rare complication of dental procedures. It is a severe medical condition characterized by a localized collection of pus between the spinal canal and dura mater. SEA can have fatal consequences in up to 16% of cases, and up to 20% of patients may experience permanent paralysis (1)(2). The most common symptoms of SEA are acute localized neck or back pain and fever. However, almost half of patients may not have a fever, leading to a delayed diagnosis. SEA is most frequently observed in patients with immunodeficiency, intravenous drug abuse, and those who underwent spinal surgery or intervention. Although the incidence of SEA following dental procedures is not well-known, it is expected to be rare. This case report describes a rare occurrence of SEA caused by Streptococcus intermedius after a dental cleaning, without tooth extraction, in a healthy patient without any immune competency or history of spine surgery.

Our case emphasizes the importance of considering SEA as a potential complication of dental procedures even in immunocompetent patients without any history of spinal surgery. Early recognition and prompt management, including surgical intervention and appropriate antibiotic therapy, may be necessary to prevent further neurological deterioration and achieve a favorable outcome.

References and Acknowledgements (Optional): 1-1. Reihsaus E, Waldbaur H, Seeling W. Spinal epidural
abscess: a meta-analysis of 915 patients. Neurosurg Rev
2000;23:175-204; discussion 5.
2. Darouiche RO, Hamill RJ, Greenberg SB, et al. Bacterial
spinal epidural abscess. Review of 43 cases and literature
survey. Medicine (Baltimore) 1992;71:369-85.