Pediatric Medical Mystery II

This is a continuation of the case presented yesterday.

The patient turned out to have a spinal epidural abscess. The radiologist read an extensive phlegmon extending from L1 to L5 impinging on the thecal sac with a septic arthritis of the L4-5 facet joint and a myositis of the paraspinous and psaos muscles. We were shocked. Spinal epidural abscesses are extremely rare, especially in a pediatric population. The risk factors are an indwelling epidural catheter and intravenous drug use, neither of which applied here. We were impressed by how extensive it was. It must have been encapsulated and growing as an abscess. Only when it broke open did the patient have meningeal signs and alarming laboratory values. We started her on ceftriaxone and vancomycin to cover staphyloccal and streptococcal species.

Neurosurgery came to evaluate the patient. At first they decided to do watchful waiting and not take her into the operating room. We also got neurology on board who suggested giving steroids to decrease cord compression. A blood culture grew out methicillin resistant Staphylococcus aureus (MRSA). Again, we became the hub of all the consult services. Eventually, the patient did not improve on intravenous antibiotics. A repeat MRI showed worsening abscess and neurosurgery did a two level laminoplasty to drain the pus. When I visited her last she was recovering well post-op and her symptoms were improving.