Abscess Triple Threat in a Diabetic Patient - PowerPoint Presentation

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Abscess Triple Threat in a Diabetic Patient

Stephanie Fong DO, Debra Craig MD

Arrowhead Regional Medical Center Colton, CA

Introduction

Patients with diabetes mellitus are susceptible to complicated infections. In particular, diabetes is a significant risk factor in the development of spinal epidural abscess (SEA) and psoas abscess (PA). However, the diagnosis of SEA and PA may be delayed or missed due to lack of clinical suspicion or consideration. We present a rare case of SEA, PA, and presacral abscess presenting simultaneously in the same patient.

Case Presentation

A 42 year old obese Hispanic male with hypertension, diabetes

mellitus, and L5-S1 fusion surgery in 2012 presented with progressive left sided lower back pain and left thigh pain for 8 days. He endorsed fever, chills, and vomiting and a history of intranasal methamphetamine use as a teenager. He denied any trauma or falls or recent travel prior to onset of symptoms. He denied any neurological complaints. The patient was septic on initial presentation and on clinical examination, he had tenderness to his low back and left thigh and no abnormal neurological signs. Estimated sedimentation rate was 119 mm/hr, C-reactive protein was 28.17 mg/dL, and white blood cells was 15.2 TH/UL with neutrophilic predominance of 56% and bandemia of 35%. MRI of the thoracic and lumbar spine revealed L5-S1 osteomyelitis, 3.9x4.5 cm presacral abscess, and 6x10 cm left psoas abscess, and 1x7cm mid L3 level to L5-S1 posterior epidural abscess causing severe spinal stenosis. The patient was started on broad spectrum intravenous antibiotics, vancomycin, cefepime, and metronidazole, and underwent emergent CT guided drainage of the left psoas abscess. Blood cultures, psoas abscess, and epidural abscess cultures were positive for methicillin-sensitive Staphylococcus aureus. The patient underwent L4-5 laminectomy on day 6 for epidural abscess drainage and washout. Repeat CT scan of the lumbar spine on day 16 revealed significant decrease in size of the left psoas abscess. The patient gradually improved after transitioning to intravenous naficillin and was discharged on day 25 with cefazolin.

Fig 1. CT abdomen and

pelvis showing 6x10 cm left psoas abscess with superior extension anterior to the L5 vertebral body and L5-S1 vertebral space

Fig 2 and 3. MRI of lumbar spine showing 1x7cm mid L3 level to L5-S1 posterior epidural abscess causing severe spinal stenosis and 3.9x4.5 cm presacral abscess

Diabetes mellitus is associated with chronic inflammation and an increased risk of opportunistic infection. In particular, diabetic patients are at risk for Staphylococcus aureus bacteremia, which may be complicated by metastatic infection. Predictive factors for metastatic infection include community acquisition, delay in adequate treatment, persistent positive blood cultures, and persistent fever.

Diabetes mellitus is a significant risk factor for SEA and PA and Staphylococcus aureus is the most commonly associated organism . Common SEA symptoms include fever, back pain, and neurological deficits, however, patients rarely present with all three symptoms. Similarly, PA has been characterized by a triad of fever, flank pain, and limp, which is only observed in 30% of patients. Despite timely diagnosis and early treatment, full recovery is expected only in 40% of SEA patients. Similarly. patients with PA have mortality ranging between 2.4 and 19%, as 20% progress to septic shock. If untreated, PA mortality approaches 100%. There is scant information available on the mortality and morbidity of patients with presacral abscesses. Therefore, given that patients with SEA and PA may present with non specific symptoms and untreated patients have significant morbidity and mortality, a high clinical suspicion is critical for timely diagnosis and treatment.

Discussion

References

1) Cohen et al. Staphylococcus aureus drives expansion of low-density neutrophils in diabetic mice. J Clin Invest. 2019 May 1; 129(5): 2133–2144.2) Chengyi JS, Benoist C, and Mathis D. The immune system’s involvement in obesity-driven type 2 diabetes. Semin Immunol. Author manuscript; available in PMC 2014 Jan 18.3) Smit J et al. Diabetes and risk of community-acquired Staphylococcus aureus bacteremia: a population-based case–control study. Eur J Endocrinol. 2016 May;174(5):631-9.4) Horino T et al. Predictive Factors for Metastatic Infection in Patients With Bacteremia Caused by Methicillin-Sensitive Staphylococcus aureus. Am J Med Sci. 2015 Jan; 349(1): 24–28.5) Flavin NE, Gomez M. Fever, Pain, and a Limp: A Case of a Psoas and Spinal Epidural Abscess Caused by Methicillin-Resistant Staphylococcus aureus in a Diabetic Patient. J Natl Med Assoc. 2009 Jan;101(1):84-6.6) Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev. 2000 Dec;23(4):175-204

Imaging

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