CASE 21
By: Dr. Sattam Lingawi and Dr. Alaa Al-Turkustani
HISTORY: 24-year-old immunocompromised patient with remote history of left temporal lobe oligodendroglioma WHO grade 2, operated 2 years back. The patient presented with gait unsteadiness, bladder and bowel incontinence, low grade fever and night sweat.
What are your findings?
What is the differential diagnosis?
FINDINGS:
Fig.1 Sagittal T2 WI, Fig.2 Sagittal post contrast T1 WI with fat saturation of the cervical spine.
Fig.3 Sagittal T2 WI, Fig.4 Sagittal post contrast T1 WI with fat saturation of the lumbar spine.
The spinal cord demonstrates multisegmental long areas of abnormal T2 hyperinensity with minimal associated cord expansion especially at C3/C4 level as well as upper and lower thoracic levels (yellow arrows) accompanied wit with meningeal enhancement (white arrows).
The lumbosacral level shows a 8.4 x 2.2 cm intraspinal–epidural T2 hyperintense collection with strong peripheral post contrast enhancement and intense meningeal enhancement (white arrows).
DIFFERENTIAL DIAGNOSIS:
Epidural abscess and myelomalecia.
Meningeal carcinomatosis.
DIAGNOSIS:
CSF analysis demonstrate very high protein 37,529 mg/L, negative for malignancy, and positive acid-fast bacilli (TB meningitis).
PEARLS AND DISCUSSION:
Isolated clinical infection of spinal epidural space without osteomyelitis/discitis is a rare infectious disorder that often has delayed diagnosis and is associated with significant morbidity and mortality. Initial clinical presentation may be fever, low backache that is non-specific and may mimic urinary tract infection, malignancy, and neuralgia. Hence, a high index of suspicion is required to diagnose such cases. MRI and diagnostic aspiration is necessary so that the pathogen-directed therapy could be instituted to prevent mortality. Most reported cases occur in the age group of 40-60 years, with very few reported in younger age groups. The commonest pathogen reported is staphylococcus aureus, and only few cases due to mycobacterium tuberculosis are reported.
FURTHER READING:
Sung Hwan Hong, MD • Ja-Young Choi, MD •MR Imaging Assessment of the Spine: Infection or an Imitation. RadioGraphics 2009; 29:599–612
Morteza Sanei Taheri, Mohammad Ali Karimi, Central Nervous System Tuberculosis: An Imaging-Focused Review of a Reemerging Disease. Hindawi Publishing Corporation Radiology Research and Practice Volume 2015, Article ID 202806
