(Kiosk 3) Progressive Bilateral Lower Extremity Weakness Due to Multiple Cervical, Thoracic, and Lumbar Abscesses Requiring Laminectomy: A Case Report

Case Diagnosis: 52 year old male with history of rectal prolapse and hemorrhoids presenting with paraparesis due to spinal epidural abscesses

Case Description or Program Description: A 52 year old male with a history of rectal prolapse requiring rectopexy and protruding hemorrhoid presented with progressive bilateral lower extremity weakness, paraesthesias, and thoracic back pain. He denied a history of IV drug use, recent spinal procedures, falls, and tuberculosis. Examination revealed 0/5 and decreased sensation throughout lower extremities. MRI spine revealed epidural abscesses throughout the cervical, thoracic, and lumbar spine with cord compression at T10-11. Blood cultures were positive for staphylococcal aureus.

Setting: Major academic and referral center with Level I adult trauma

Assessment/Results: The patient underwent posterior T7-T10 thoracic laminectomy with neurosurgery. He was transferred to inpatient rehabilitation (IPR) requiring maximal assistance with bed mobility, transfers, and ADLs. During his rehabilitation course, he developed a cardiac murmur due to severe aortic insufficiency with small vegetation. He underwent aortic valve replacement and CABG. He was readmitted to IPR when sternal precautions were lifted; he improved to the level of minimal assistance for bed mobility and minimal to moderate assistance for transfers.

Discussion (relevance): This case demonstrates a male patient with progressive paraparesis due to spinal epidural abscesses (SEA), which more often affects men older than 50. Although this is rare, there is an increasing number of diagnosed cases due to increased spinal procedures and rates of IV drug use. Other etiologies include diabetes, HIV, tuberculosis, acupuncture, lumbar puncture, CNS surgery, and bacteremia most commonly due to staphylococcal aureus. If bacteremia and SEA are not treated, further complications may arise such as endocarditis, UTI, or mortality.

Conclusions: Given that the patient had no other risk factors for developing SEA, it's suspected that the protruding hemorrhoid served as a nidus for bacterial entry, allowing for hematogenous spread to the epidural space. Though this seems to be rare, there is a documented case of rectopexy leading to bacteremia and infection of the epidural space. Early diagnosis of SEA is essential in preventing paraparesis; this case implies that the risk of SEA should be emphasized in those with hemorrhoids or other sources of infection in the region.