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      Lumbar spine epidural abscess and facet joint septic arthritis due to Streptococcus agalactiae: a case report

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          Abstract

          Background

          Here we report a rare case of lumbar spine epidural abscess and facet joint septic arthritis caused by Streptococcus agalactiae, which had spread to the iliopsoas muscles, leading to urine retention.

          Case presentation

          A 68-year-old woman with low back pain experienced a sudden onset of bilateral lower limb weakness, it was followed 14 days later by urine retention. At consultation, magnetic resonance imaging and identification of serum β-hemolytic streptococci provided a diagnosis of Streptococcus agalactiae infection. She was started on antibiotics. Despite diminishing signs of inflammation, preoperative MRI showed an epidural mass at T12-L4 compressing the cord and involving the paravertebral muscles as well. Group B beta-hemolytic streptococci were detected in both urine and blood. Because of bilateral lower limb weakness and urine retention, T12-L4 hemilaminectomy was performed. The L3/L4 intertransverse ligament resected and abscess drained. Histopathology revealed that inflammatory cells had invaded the facet joint. Group B beta-hemolytic streptococci were identified, confirming the diagnosis. The patient continued with the antibiotics postoperatively, and her health rapidly improved.

          Conclusion

          Lumbar spine epidural abscess and facet joint septic arthritis caused by Streptococcus agalactiae is a clinical emergency, with significant morbidity and mortality especially with delayed diagnosis. A delay in both diagnosis and aggressive treatment can lead to not only severe neurological deficit but also to septicaemia, multiorgan failure, and even death.

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          Most cited references18

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          Spinal epidural abscess: a meta-analysis of 915 patients.

          Spinal epidural abscess (SEA) was first described in the medical literature in 1761 and represents a severe, generally pyogenic infection of the epidural space requiring emergent neurosurgical intervention to avoid permanent neurologic deficits. Spinal epidural abscess comprises 0.2 to 2 cases per 10,000 hospital admissions. This review intends to offer detailed evaluation and a comprehensive meta-analysis of the international literature on SEA between 1954 and 1997, especially of patients who developed it following anesthetic procedures in the spinal canal. In this period, 915 cases of SEA were published. This review is the most comprehensive literature analysis on SEA to date. Most cases of SEA occur in patients aged 30 to 60 years, but the youngest patient was only 10 days old and the oldest was 87. The ratio of men to women was 1:0.56. The most common risk factor was diabetes mellitus, followed by trauma, intravenous drug abuse, and alcoholism. Epidural anesthesia or analgesia had been performed in 5.5% of the patients with SEA. Skin abscesses and furuncles were the most common source of infection. Of the patients, 71% had back pain as the initial symptom and 66% had fever. The second stage of radicular irritation is followed by the third stage, with beginning neurological deficit including muscle weakness and sphincter incontinence as well as sensory deficits. Paralysis (the fourth stage) affected only 34% of the patients. The average leukocyte count was 15,700/microl (range 1,500-42,000/microl), and the average erythrocyte sedimentation rate was 77 mm in the first hour (range 2-50 mm). Spinal epidural abscess is primarily a bacterial infection, and the gram-positive Staphylococcus aureus is its most common causative agent. This is true also for patients who develop SEA following spinal anesthetics. Magnetic resonance imaging (MRI) displays the greatest diagnostic accuracy and is the method of first choice in the diagnostic process. Myelography, commonly used previously to diagnose SEA, is no longer recommended. Lumbar puncture to determine cerebrospinal fluid protein concentrations is not needed for diagnosis and entails the risk of spreading bacteria into the subarachnoid space with consequent meningitis; therefore, it should not be performed. The therapeutic method of choice is laminectomy combined with antibiotics. Conservative treatment alone is justifiable only for specific indications. Laminotomy is a therapeutic alternative for children. The mortality of SEA dropped from 34% in the period of 1954-1960 to 15% in 1991-1997. At the beginning of the twentieth century, almost all patients with SEA died. Parallel to improvements in the mortality rate, today more patients experience complete recovery from SEA. The prognosis of patients who develop SEA following epidural anesthesia or analgesia is not better than that of patients with noniatrogenic SEA, and the mortality rate is also comparable. The essential problem of SEA lies in the necessity of early diagnosis, because only timely treatment is able to avoid or reduce permanent neurologic deficits. The problem with spinal epidural abscesses is not treatment, but early diagnosis - before massive neurological symptoms occur" (Strohecker and Grobovschek 1986).
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            Group B streptococcal infections in elderly adults.

            Elderly adults account for >40% of persons with invasive group B streptococcal (GBS) disease and for >50% of GBS-associated deaths in the United States. The prevalence of colonization among healthy elderly adults (approximately 25%) is similar to that among women of childbearing age. Delineating contributions of comorbid conditions, altered integrity of anatomical barriers, and abnormalities in immune responses caused by immune senescence to pathogenesis require further investigation. Delayed clinical recognition of illness may contribute to poor outcome. Skin and soft-tissue infections and bacteremia with no identified focus are common manifestations of infection in elderly adults and younger nonpregnant adults. Urinary tract infection and pneumonia are presentations more often encountered in elderly persons than in younger adults. The safety and immunogenicity of GBS serotype V-tetanus toxoid conjugate vaccine in healthy elderly persons suggest the potential for vaccination as an approach to prevention of invasive GBS infections in elderly persons.
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              The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess.

              Previous reports have recommended the use of a "classic triad" of fever, spine pain, and neurologic deficits to diagnose spinal epidural abscess (SEA); however, the prognosis for complete recovery is poor once these deficits are present. This retrospective case-control study investigates the impact of diagnostic delays on outcome and explores the use of risk factor screening for early identification of SEA in a population of ED patients. Inpatients with a discharge diagnosis of SEA and a related ED visit before the admission were identified over a 10-year time period. In addition, a pool of ED patients presenting with a chief complaint of spine pain was generated; controls were hand-matched 2:1 to each SEA patient based on age and gender. Data regarding demographics, presence of risk factors, physical examination findings, laboratory and radiographic results, and clinical outcome were abstracted from medical records and entered into a database for further analysis. Patients with SEA were compared to matched controls with regard to the prevalence of risk factors and the "classic triad." We also explored the impact on outcome of diagnostic delays, defined as either: 1) multiple ED visits before diagnosis, or 2) admission without a diagnosis of SEA and >24 h to a definitive study. A total of 63 SEA patients were hand-matched to 126 controls with spine pain. Diagnostic delays were present in 75% of SEA patients. Residual motor weakness was present in 45% of these patients vs. only 13% of patients without diagnostic delays (odds ratio 5.65, 95% C.I. 1.15-27.71, p < 0.05). The "classic triad" of spine pain, fever, and neurologic abnormalities was present in 13% of SEA patients and 1% of controls during the initial visit (p < 0.01); one or more risk factors were present in 98% of SEA patients and 21% of controls (p < 0.01). The erythrocyte sedimentation rate (ESR) was more sensitive and specific than total white blood cell (WBC) count as a screen for SEA. In conclusion, diagnostic delays are common in patients with SEA, often leading to irreversible neurologic deficits. The use of risk factor assessment is more sensitive than the use of the classic diagnostic triad to screen ED patients with spine pain for SEA. The ESR may be a useful screening test before magnetic resonance imaging in selected patients.
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                Author and article information

                Contributors
                +81-99-275-5381 , upendocostansia@gmail.com
                hiro-tom@m2.kufm.kagoshima-u.ac.jp
                tyamamo@m2.kufm.kagoshima-u.ac.jp
                setoro@m2.kufm.kagoshima-u.ac.jp
                hidekik@m2.kufm.kagoshima-u.ac.jp
                naga@m2.kufm.kagoshima-u.ac.jp
                kichirochan@yahoo.co.jp
                masa@m3.kufm.kagoshima-u.ac.jp
                kakoi@m2.kufm.kagoshima-u.ac.jp
                ishidou@m2.kufm.kagoshima-u.ac.jp
                skomiya@m3.kufm.kagoshima-u.ac.jp
                Journal
                BMC Surg
                BMC Surg
                BMC Surgery
                BioMed Central (London )
                1471-2482
                13 March 2018
                13 March 2018
                2018
                : 18
                : 16
                Affiliations
                [1 ]ISNI 0000 0001 1167 1801, GRID grid.258333.c, Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, , Kagoshima University, ; 8-35-1 Sakuragaoka, Kagoshima, 890-8520 Japan
                [2 ]ISNI 0000 0001 1167 1801, GRID grid.258333.c, The Near-Future Locomotor Organ Medicine Creation Course (Kusunoki Kai), Graduate School of Medical and Dental Sciences, , Kagoshima University, ; Kagoshima, Japan
                [3 ]ISNI 0000 0004 0377 8088, GRID grid.474800.f, Division of Medical and Environmental Safety, , Kagoshima University Medical and Dental Hospital, ; Kagoshima, Japan
                [4 ]ISNI 0000 0001 1167 1801, GRID grid.258333.c, Medical Joint Materials, Graduate School of Medical and Dental Sciences, , Kagoshima University, ; Kagoshima, Japan
                [5 ]Department of Neurosurgery, Muhimbili Orthopaedic and Neurosurgical Institute, P.O. Box 65474, Dar es Salaam, Tanzania
                Author information
                http://orcid.org/0000-0001-8180-7583
                Article
                350
                10.1186/s12893-018-0350-2
                5851089
                29534714
                23c67b09-8f2e-4ebc-97c9-a885947eb0a0
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 22 November 2017
                : 6 March 2018
                Categories
                Case Report
                Custom metadata
                © The Author(s) 2018

                Surgery
                spinal epidural abscess,facet joint septic arthritis,streptococcus agalactiae,urine retention,antibiotic administration,hemilaminectomy

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