Epidural abscess is a rare and severe infectious condition of the spine, with an incidence between 0.2% and 1.2% in the general population and up to 5% in immunocompromised patients, often associated with severe complications and high mortality. Although it can occur at any age, it is more common in individuals in the sixth and seventh decades of life. Risk factors include immunosuppression, drug use, and invasive procedures. Its clinical presentation is variable; fever, pain and neurologic symptoms are common, although the classic triad is not always present, which hampers diagnostic suspicion. Magnetic resonance imaging is the method of choice, showing epidural collections with hypointense signal on T1, hyperintense signal on T2 and adjacent edema. The main causative agents are staphylococci, Gram-negative bacilli and Pseudomonas spp. Combined treatment with surgery and antibiotic therapy is essential to reduce mortality. A 21-year-old female patient, previously healthy, presented with a one-week history of low back pain, along with thrombocytopenia, anemia and leukocytosis. Initially treated as pyelonephritis in other services, she was admitted for further investigation. On the second day, she developed urinary retention with a distended bladder and paraplegia. CT scan showed an epidural collection from T3 to T9, and she underwent laminectomy, which revealed a lesion in the posterior epidural space, yellow-green in color and adherent to the dura mater. Cultures for bacteria and fungi were negative, which does not exclude the diagnosis of epidural abscess, since up to 30% of cases may have sterile cultures due to fastidious microorganisms, inadequate technique or previous antibiotic therapy. Despite treatment with vancomycin and piperacillin/tazobactam, there was persistent lymphocytosis and the presence of blasts, and bone marrow karyotyping showed a translocation 8;21, confirming acute myeloid leukemia. Treatment with cytarabine and daunorubicin was initiated. The case was recorded after informed consent. This report highlights the complexity of diagnosing epidural abscess, especially in patients with underlying hematologic diseases, and underscores the importance of early evaluation and inclusion of differential diagnoses even in young, previously healthy patients, as delays can result in irreversible neurologic sequelae.
Bernardes et al. (Sun,) studied this question.