Chronic Spinal Cord Abscess in an Elderly Patient

An 82-year old male with diabetes mellitus presented with a four-month history of backache and some difficulty walking without sphincter disturbance or fever. Neurologic examination showed moderate left lower-extremity weakness with the Babinski sign. Chest and spinal radiographs and laboratory studies were normal. Spinal magnetic resonance imaging (MRI) revealed a mid-thoracic intramedullary ring-like lesion (Fig. 1). A metastasis was suspected, but Escherichia coli was identified on urinary culture. The lesion was then believed to be an intramedullary abscess.

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FIG. 1.

Spinal sagittal T₂-weighted magnetic resonance scan (A) reveals intramedullary cystic lesion (black star) at T6–T7. Axial (B) and coronal T₁-weighted (C) scans after gadolinium infusion show ring-like enhancement of spinal cord lesion (white star).

Because of the small size of the abscess, the patient's advanced age, diabetes mellitus, the identification of the pathogen, and the moderate neurologic deficit, we did not perform surgery immediately. The patient was treated with steroids associated with intramuscular gentamicin (10 days) and intravenous ciprofloxacin for four weeks (200 mg/8 h) followed by oral ciprofloxacin (1 g/day) for two months. The symptoms gradually improved within the first week, and the abscess resolved after three months.

Spinal cord abscesses (SCA) are rare, and most cases occur in the first and third decades of life [1–5]. Acute SCA may present as spinal cord syndrome with back pain and fever, contrasting with chronic abscesses, which tend to have a less specific symptomatology, especially in the elderly. In MRI, the T₁-weighted images show decreased signal intensity with peripheral enhancement after gadolinium injection; this finding can be indistinguishable from neoplasm [2,3]. Special attention should be paid to the possibility of sinus tracts in children and metastatic infectious causes in adults [1–4]. Secondary abscesses arise from another infection site, most commonly in the lung, spine, heart valve, or genitourinary system, as in our case. Various organisms have been isolated, but Streptococcus and Staphylococcus are the most common causative bacterial agents [5].

Classically, treatment involves a combination of surgical drainage of the abscess cavity, identification of the infecting organism, and administration of appropriate antibiotics. Medical therapy alone may be appropriate in patients with few symptoms and with serious medical problems, especially if an infective organism can be identified, as in our case. If the diagnosis is unclear or patients do not respond to medical management, surgical decompression should be performed [4].