Spinal Epidural Abscess: A Diagnostic Challenge -- American Family Physician

www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1341 prior medical history included diabetes mellitus, hypertension, and depression. The patient was alert and oriented, and had stable vital signs but was mildly febrile. Positive physical findings included poor dentition, periodontal disease, diffusely tender abdomen, decreased rectal sphincter tone, absence of deep tendon reflex in both lower extremities, and mild tenderness on palpation of the lower thoracic spine and upper lumbar region with no external evidence of injury. Chest and abdominal radiographs were unremarkable. Initial laboratory investigation showed leukocytosis with a left shift (white blood cell count [WBC], 22,000 per mm [22 10 per L] with 68 percent neutrophils S pinal epidural abscess has an estimated incidence rate of 0.2 to 2.8 cases per 10,000 per year, with the peak incidence occurring in people who are in their 60s and 70s. The most common causative agent is Staphylococcus aureus. Epidural abscess caused by actinomycosis is rare; fewer than 80 cases have been reported since the organism was identified in 1878. The incidence of spinal epidural abscess appears to have increased in the United States since the 1980s, possibly because of an increase in the age of the population, the number of spinal procedures performed, intravenous (IV) drug abuse, and the number of patients with acquired immunodeficiency syndrome (AIDS). Associated predisposing conditions include a compromised immune system such as occurs in patients with diabetes mellitus, AIDS, chronic renal failure, alcoholism, or cancer, or following epidural anesthesia, spinal surgery, or trauma (Table 1). No predisposing condition can be found in 20 percent of patients with spinal epidural abscess, and the condition has been reported in patients with no predisposing risk factors.