Myelitis Secondary to Bacterial, Fungal, Parasitic, and Granulomatous Diseases
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With few exceptions, this class of spinal cord disease seldom offers any dif culty in diagnosis The CSF usually holds the clue to causation In most cases, the in ammatory reaction in the meninges is only one manifestation of a generalized (systemic) disease process The spinal lesion may involve primarily the pia-arachnoid (leptomeningitis), the dura (pachymeningitis), or the epidural space, eg, taking the form of an abscess or granuloma; in the last circumstance, damage to the spinal cord is due to compression and ischemia In some acute forms, both the spinal cord and meninges are simultaneously affected, or the cord lesions may predominate Chronic spinal meningitis may involve the pial arteries or veins; and as the in amed vessels become thrombosed, infarction (myelomalacia) of the spinal cord results Chronic meningeal in ammation may provoke a progressive constrictive pial brosis (socalled spinal arachnoiditis) that virtually strangulates the spinal cord In certain instances, spinal roots become progressively damaged, especially the lumbosacral ones, which have a long meningeal exposure Posterior roots, which enter the subarachnoid space near arachnoidal villi (where CSF is resorbed), tend to suffer greater injury than anterior ones (as happens in tabes dorsalis) Interestingly, there are cases of chronic cerebrospinal meningitis that remain entirely without symptoms until the spinal cord or roots become involved The infrequent but unique bacterial myelitis caused by the atypical pneumonia agent Mycoplasma pneumoniae has come to be viewed as a postinfectious immune disease, as discussed on page 601 However, portions of the DNA from this organism have been found in the spinal uid early in the course of illness in some cases (using the polymerase chain reaction), suggesting instead a direct bacterial infection of the spinal cord (see Chap 32) It is not known whether antibiotic treatment alters the course of the illness Syphilitic myelitis is discussed on page 618 Bacterial abscess of the spinal cord (acute bacterial myelitis) is rare (especially in
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DISEASES OF SPINAL CORD, PERIPHERAL NERVE, AND MUSCLE
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comparison to epidural spinal abscess) and is only beginning to be recognized by MRI At times it stands as a single pyogenic metastasis, but more often there has been spread from a contiguous infected surgical site or a stulous connection with a super cial paraspinal abscess or a distant infection and subsequent bacteremia As stated, spinal epidural abscess and granuloma are the more important representatives of this group Sarcoid myelitis (see also page 613) Sarcoid granulomas may present as one or more intramedullary spinal cord masses, as in the cases reported by Levivier and colleagues In our experience the granulomatous lesion, which may be focal or multifocal, simulates demyelinative disease with respect to its tendency to relapse and remit and in its notable but inconsistent response to corticosteroids (page 614) An asymmetrical ascending paraparesis and bladder disturbance have been the main features in our patients Usually there is evidence of disseminated sarcoidosis and the CSF is abnormal (increase in cells and protein), but we have encountered several instances of sarcoid restricted to the spinal cord before it was evident in the mediastinum (ie, chest CT failing to demonstrate hilar adenopathy) Elevation of the spinal uid IgG concentration and the presence of oligoclonal bands are typical but not constant in these cases of neurosarcoidosis; often there are activated histiocytes in the CSF The use of angiotensin-converting enzyme levels in the CSF to distinguish sarcoidosis from MS suffers from the lack of normative values for this test, but it is said to be elevated in two-thirds of patients The MRI is abnormal and the conus or other portions of the cord reveal intramedullary lesions The most characteristic nding, however, is a multifocal-subpial nodular enhancement of the meninges adjacent to a lesion of the cord or nerve roots a picture which to some extent resembles neoplastic meningeal in ltration The diagnosis can be con rmed by mediastinal lymph node biopsy or by the less desirable method of biopsy of the spinal meninges and affected subpial cord A number of other rare granulomatous conditions have on occasion caused an intrinsic or, more often, an extrinsic compressive myelopathy, including brucellosis, xanthogranulomatosis, and eosinophilic granuloma The diagnosis may be suspected if the systemic disease is apparent at the time, but in some instances only the histology of a surgical specimen reveals the underlying process Spinal Epidural Abscess This condition is worthy of emphasis because the diagnosis is often missed or mistaken for another disease, sometimes with disastrous results Children or adults may be affected Infection of the epidural space has a wide variety of sources Staphylococcus aureus is the most frequent etiologic agent, followed in frequency by streptococci, gram-negative bacilli, and anaerobic organisms An injury to the back, often trivial at the time, furunculosis or other skin or wound infection, or a bacteremia may permit seeding of the spinal epidural space or of a vertebral body This gives rise to osteomyelitis with extension of the purulent process to the epidural space Occasionally, it spreads from an infected disc One frequent source is a septicemia in a drug addict following the use of nonsterile needles or the injection of contaminated drugs In other cases organisms may be introduced into the epidural space during spinal surgery or rarely via a lumbar puncture needle during epidural or spinal anesthesia or from epidural injections of steroid or other therapeutic agents The localization in these latter instances is over the lumbar and sacral roots In these cases of cauda equina epidural abscess, back pain may be severe and neurologic symptomatology minimal unless the infection extends
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upward to the upper lumbar and thoracic segments of the spinal cord At rst, the suppurative process is accompanied only by lowgrade fever and aching local back pain, usually intense, followed within a day or several days by radicular pain in most cases Headache and nuchal rigidity are sometimes present; more often there is just the persistent pain and a disinclination to move the back After several more days, there is the onset of a rapidly progressive paraparesis and paraplegia or quadriplegia associated with sensory loss in the lower parts of the body and sphincteric paralysis Percussion of the spine elicits considerable tenderness over the site of the infection Examination discloses all the signs of a complete or partial transverse cord lesion, occasionally with elements of spinal shock if paralysis has evolved rapidly, which is rare If a spinal puncture has been performed, the CSF contains a relatively small number of white cells (usually fewer than 100 per cubic millimeter), both polymorphonuclear leukocytes and lymphocytes, unless the needle penetrates the abscess, in which case pus is obtained The protein content is high (100 to 400 mg/100 mL or more), but the glucose is normal Elevation of the sedimentation rate and peripheral neutrophilic leukocytosis are important clues (often neglected) to the diagnosis (Baker et al) Treatment The foregoing clinical ndings call for immediate MRI (Fig 44-2) or CT, the latter preferably with myelography, to demonstrate the abscess and determine its level If not treated surgically by laminectomy and drainage at the earliest possible time, before the onset of paralysis, the spinal cord lesion, which is due in part to ischemia (compression mainly of veins), becomes more or less irreversible Broad spectrum antibiotics in large doses must be given initially and the choice of treatment is then re ned based on cultures from the abscess or the blood, or on the presumed source of bacteria Cauda equina epidural abscess without neurologic signs may in many cases be treated solely with antibiotics, although some surgeons favor drainage, which must be undertaken in any case if osteomyelitis develops When osteomyelitis of a vertebral body is the primary abnormality, the epidural extension may implicate only a few spinal sensory and motor roots, leaving long tracts and other intramedullary structures intact In some cases with cervical epidural abscesses, stiff neck, fever, and deltoid-biceps weakness are the main neurologic abnormalities Having emphasized the urgency of treatment, there are instances of small epidural abscesses that do not compress the cord and are limited to one or at most two levels for which we have avoided surgery by administering antibiotics alone Antibiotics need to be continued for several weeks, and the patient should be examined at regular intervals and have sequential MRI scans of the affected region Even after apparently successful drainage and antibiotic treatment of an epidural abscess, there may be a slowly progressive and then stabilizing syndrome of incomplete cord compression This is the result of formation of a brous and granulomatous reaction at the operative site Distinguishing this in ammatory mass from residual epidural abscess may be dif cult, even with enhanced MRI, but persistent fever, leukocytosis, and an elevated sedimentation rate should suggest that surgical drainage of the abscess was incomplete Spinal subdural bacterial infections also occur and, clinically, are virtually indistinguishable from epidural ones on clinical grounds A clue is provided by the CT myelogram, in which the subdural lesion has a less sharp margin and a greater vertical extent The difference in con guration is also appreciated on MRI The epidural and subdural infections, if they smolder owing to delayed
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