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Two Cases of Spontaneous Epidural
Abscess in Patients With Cirrhosis
from
Southern
Medical Journal
Posted 04/15/2003
Raymond
K. Cross Jr., MD, Charles Howell, MD
http://www.medscape.com/viewarticle/451615
Abstract and Introduction
Abstract
Medical
conditions predisposing to epidural abscess include diabetes,
intravenous drug use, alcoholism, and other immunocompromised
states. Although cirrhosis is associated with an increased
risk of infection in general it has not previously been
identified as a condition predisposing to epidural abscess. We
describe two cirrhotic patients with spinal epidural
abscesses. We speculate that the underlying immune defects
associated with cirrhosis increase the risk of spontaneous
epidural abscess and should raise concern for this infection
when cirrhotic patients present with fever and back pain.
Introduction
Spinal
epidural abscess is an uncommon condition, with an incidence
between 0.2 and 2.8 per 10,000 hospital admissions. Infection
of the epidural space may develop by direct extension of
infection from an adjacent vertebra or intervertebral disc,
from overlying skin, pharynx, and kidney or by hematogenous
spread from remote infections. Patients undergoing invasive
spinal procedures and patients who suffer blunt trauma to the
spine are also at risk for epidural abscess. Medical
conditions predisposing to epidural abscesses include diabetes
mellitus, intravenous drug abuse, chronic renal failure,
alcoholism, and cancer.[1-3]
To our knowledge, chronic liver disease has not previously
been identified as a condition predisposing to epidural
abscesses. We describe two cases of spontaneous epidural
abscess in women with underlying cirrhosis.
http://www.medscape.com/viewarticle/451615_2
Two Cases of Spontaneous Epidural Abscess in Patients
from
Southern
Medical Journal
Case Reports
Patient 1
A
47-year-old woman presented with acute onset of fever,
jaundice, flank tenderness, and confusion. Her blood cultures
yielded Staphylococcus aureus. She was treated with
intravenous vancomycin but continued to have elevated
temperatures and bacteremia. A lumbar puncture revealed a
white blood cell count of greater than 1,200/mm3. Cerebrospinal fluid Gram's stain and cultures were negative. She
had no history of HIV, diabetes, liver or renal disease,
cancer, or recent trauma. She had drunk two glasses of Wild
Irish Rose per day for years but denied illicit drug use.
Physical examination revealed a temperature of 39.4°C, blood
pressure 90/50 mm Hg, and a heart rate of 120 beats/min. The
sclerae were icteric. Bibasilar rales were present. A II/VI
systolic murmur at the base and lower left sternal border was
present. Ascites and anasarca was present. She was not
oriented to time or location and asterixis was present. The
remainder of the neurologic examination was normal. Laboratory
tests revealed blood urea nitrogen (BUN) of 33 mg/dl,
creatinine of 3.3 mg/dl, glucose of 50 mg/dl, aspartate (AST)
78 IU/dl, alkaline phosphatase 135 IU/dl, bilirubin 15.6
mg/dl, and International Normalized Ratio (INR) 1.6. Hepatitis
A, B, and C serologies were non reactive. Antinuclear (ANA),
antimitochondrial (AMA), and anti-smooth muscle (ASMA)
antibodies were also nonreactive. Levels of
 1-antitrypsin and ceruloplasmin were normal.
Because of her history of alcohol use and abnormal liver
synthetic function, she was presumed to have alcoholic
cirrhosis. She was given ceftriaxone, vancomycin, furosemide,
and lactulose. She was then transferred to our hospital. A
contrast computed tomographic scan of the head was
unremarkable. Bibasilar atelectasis and small pleural
effusions were present on computed tomographic scans of the
chest. An echocardiogram revealed no vegetations. A lumbar MRI
showed an epidural abscess at L4-L5. During the third week of
antibiotic therapy, she developed recurrent fever and lower
extremity weakness and numbness; because of emerging
neurologic deficits, she underwent uneventful L4-L5
laminectomy and drainage of the abscess. Culture of the
abscess yielded coagulase negative Staphylococcus.
Patient 2
A
54-year-old woman with cirrhosis due to chronic hepatitis C
infection presented with left sided flank and buttock pain,
difficulty ambulating, anorexia, worsening ascites, and
confusion. She was given "pain medication" and
"antispasmodics" without relief. She was transferred
to our hospital for further evaluation. She denied a history
of HIV, diabetes, renal failure, cancer, or recent trauma. The
patient drank two bottles of beer per week but denied illicit
drug use. Physical examination revealed a temperature of 36.7°C,
blood pressure 134/66 mm Hg, and a heart rate of 107
beats/min. The sclerae were icteric. The pharynx was
erythematous and thrush was present. She had decreased breath
sounds in the lung bases. A Grade III/VI systolic murmur was
present at the left sternal border. The abdomen was tender in
the right lower quadrant and ascites was present. The stool
examination was Hemoccult positive. She was lethargic but was
oriented to person, place, and time. The remainder of the
neurologic examination was normal. The white blood cell count
was 11,400/mm3,
hematocrit was 23.1%, and platelet count was 100,000/mm3. Total bilirubin was 15.3 mg/dl, AST 271 IU/dl,
alanine (ALT) 96 IU/dl, alkaline phosphatase 364 IU/dl,
albumin 1.4 g/dl, and total protein 7.3 g/dl. The patient
developed nightly fevers and was administered intravenous
nafcillin. Blood cultures yielded Staphylococcus aureus;
cefazolin was started and nafcillin was discontinued after the
sensitivities became available. An echocardiogram did not
reveal vegetations. The patient continued to report bilateral
buttock pain. A MRI of the lumbar spine revealed an epidural
abscess at L5-S1. Neurosurgery recommended antibiotic
treatment without surgical drainage. Intravenous antibiotics
were continued for two months, followed by oral dicloxacillin
for two months. She remained well off antibiotics.
http://www.medscape.com/viewarticle/451615_3
Two Cases of Spontaneous Epidural Abscess in Patients
from
Southern
Medical Journal
Discussion
Infection
is an important cause of both morbidity and mortality in
patients with cirrhosis. Thirty to fifty percent of
hospitalized patients with cirrhosis are infected at the time
of presentation or become infected during their
hospitalization. The most common sites of infection include
the urinary tract, peritoneum, lower respiratory tract, and
the skin and soft tissues.[4]Escherichia
coli
and other aerobic Gram negative bacteria are the most common
etiologic agents identified, although Staphylococci and
Streptococci are responsible for one fourth of all infections.[5]
Several
factors predispose cirrhotic patients to infection (Table
1). Patients with cirrhosis are prone to small bowel
bacterial overgrowth, which has been shown to correlate with
increased rates of infection, particularly spontaneous
bacterial peritonitis (SBP).[6,
7]
Moreover, portal hypertension induces alterations in the bowel
wall and mesenteric lymphatics, which promote translocation of
intestinal bacterial from the bowel lumen into regional
lymphatics.[8] Indeed, translocation of enteric bacteria has been proposed as an
early step in bacteremia in multiple settings including cancer
chemotherapy, sepsis, hypovolemic shock, and multiorgan
failure and is thought to be a critical element in the
pathogenesis of SBP.[9-11] Cirrhosis has also been shown to be
associated with depressed phagocytic activity within the
liver, spleen and macrophages, decreased neutrophil function,
and decreased levels of serum complement and fibronectin, all
of which might predispose patients to a variety of infections,
including epidural abscesses.[2, 12-14]
http://www.medscape.com/viewarticle/451615_4
Two Cases of Spontaneous Epidural Abscess in Patients
from
Southern
Medical Journal
Conclusion
To
our knowledge, this article describes the first series in
which a link was found between epidural abscess and cirrhosis.
It is not surprising that severe infections such as these
exist in patients with cirrhosis; indeed multiple
abnormalities of the immune system exist in patients with
chronic liver disease. Epidural abscess should be considered
as a potential source of infection in cirrhotic patients,
especially those with fever and back pain.
Acknowledgements
We
acknowledge Philip A. Mackowiak, MD, professor and vice chair,
Department of Medicine, University of Maryland School of
Medicine, and director, Medical Care Clinical Center,
Baltimore Veterans Affairs Medical Center, Baltimore, MD.
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