Obstructing Renal Calculi Masking an Epidural Abscess: A Rare Presentation

1Johns Hopkins Bayview Medical Center, Baltimore, MD
2Johns Hopkins Bayview Medical Center, Baltimore, MD
3Deccan College of Medical Sciences, Hyderabad, India
4Shadan College of Medical Sciences, Hyderabad, India
5Kakatiya Medical College, Warangal, India

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 501

Case Presentation:

A 65‐year‐old woman with a history of mild lumbar spinal stenosis and osteoarthritis came to the emergency room with a 4‐day complaint of progressively worsening back pain radiating to the abdomen. She suffered from chronic back/knee pain that was managed nonsurgically with pain medications. On arrival her initial vitals were stable; exam was impressive for morbid obesity (BMI 45), tenderness in the midback/paraspinal area and limited mobility from pain. No signs or symptoms of cord compression were evident. Her labs were significant for WBCs of 15,740/mm3, platelet count of 94,000/mm3, creatinine 1.8 mg/dL, BUN 38 mg/dL, and bilirubin 3.1 mg/dL. A CT abdomen/pelvis revealed obstructing renal calculi (0.5 × 0.7 × 2.1 cm) with hydronephrosis/hydroureter of the left kidney. She was treated with Ceftriaxone. Urine culture grew Escherichia coli. The patient was sent for a left nephrostomy tube placement and the cultures from it also grew Escherichia coli sensitive to Ceftriaxone. Her renal failure, thrombocytopenia and hyperbilirubinemia (cholestasis from naproxen) resolved after nephrostomy and stopping naproxen. Given her unrelenting symptoms, persistent leukocytosis and new neurological findings of hyperreflexia in her lower extremities an MRI spine was done. MRI spine showed epidural abscess (extending from T4 through L2), discitis, osteomyelitis (L1 and L2 vertebrae) and cord compression from the abscess. Neurosurgeons took the patient for emergent laminectomy, decompression and evacuation. Antibiotic coverage broadened to cefipime, vancomycin and metronidazole. Blood cultures and epidural abscess cultures were negative. Infectious disease was consulted who changed the antibiotics to vancomycin and Ceftriaxone for duration of six weeks. The most likely source of pathogen was urinary tract. Given patient got antibiotics prior to having her epidural abscess drained could have rendered the cultures negative.

Discussion:

Epidural abscess is a diagnostic challenge for hospitalists. Literature supports a growth in the incidence of epidural abscesses in hospitalized patients. The symptom triad of fever, back pain, and neurological symptoms associated with epidural abscess is not always present in patients. Abdominal pain is one of the atypical presentations in thoracic epidural abscess. This could be misguiding for clinicians if patients have other pathologies accounting for the symptom complex. This can lead to missing or delay in the diagnosis of epidural abscess. A delay in diagnosis leads to permanent neurological damage. Renal calculi can act both as a source of infection and also a source of masking the clinicians' vision of suspecting atypical presentations of epidural abscess.

Conclusions:

Here, we present an unusual case of spinal epidural abscess that was masked by presence of an obstructing renal calculus. Hospitalists should be aware of atypical presentations of epidural abscess.

To cite this abstract:

Gundareddy V, Bollampally P, Thamtam V, Ravi S, Ravi G. Obstructing Renal Calculi Masking an Epidural Abscess: A Rare Presentation. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 501. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/obstructing-renal-calculi-masking-an-epidural-abscess-a-rare-presentation/. Accessed May 22, 2019.

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