Letters to the Editor

Case Report

Brucellar Spinal Epidural Abscess

Am Fam Physician. 2003 May 15;67(10):2071-2072.

to the editor: Spinal epidural abscess is a rare condition that can lead to irreversible complications and death if untreated. The most common causative agent is Staphylococcus aureus, and other responsible agents include gram-negative bacteria, Streptococcus species, coagulase-negative Staphylococci, Streptococcus pneumoniae, Haemophilus aphrophilus, Nocardia asteroides, Echinococcus, Aspergillus, and Candida spp.1,2 Chronic epidural infection may be caused by Mycobacterium tuberculosis, frequently without other evidence of infection. Rare causes include Actinomyces israelii2 and Actinomyces odontolyticus.1 In endemic areas such as South America, Central America, Mediterranean countries, Europe, and Africa, Brucella may produce spondylodiscitis, which may be complicated by spinal epidural abscesses.35 The following case report is of spinal epidural abscess caused by systemic Brucella melitensis infection.

A 34-year-old Greek stockbreeder presented with a two-week history of fever, anorexia, headache, night sweats, and low back pain. The lumbar pain radiated along the S1 root and increased in intensity over four days. His medical history was unremarkable.

During examination, he exhibited tenderness to palpation of the lower lumbar spine despite having no external evidence of injury. Strength and reflexes were normal in bilateral lower extremities, but there was decreased sensation along the sciatic nerve in the left leg.

The patient was placed on intravenous ceftriaxone and dicloxacillin. A transesophageal echocardiogram was normal. A magnetic resonance imaging (MRI) of the spine showed spondylitis at L5 and a paraspinal soft tissue fluid collection at L5-S1. Three blood culture specimens yielded B. melitensis, and the Brucella seroagglutination test was positive in a titer of 1:2,560. A computed tomography-guided needle aspiration of the paravertebral collection yielded purulent material that also grew B. melitensis. The patient's antibiotic regimen was changed to streptomycin for 15 days and both doxycycline and rifampin for three months. His clinical course improved, and he recovered without neurologic sequelae.

Brucellosis is a multisystem disease caused by Brucella spp. Humans become infected from contact with infected animals and animal products, particularly milk and cheese. Neurologic involvement during the acute phase of Brucella infection affects between 2 and 5 percent of patients in the form of meningitis, encephalitis, myelitis-radiculo-neuritis, brain abscess, epidural abscess, demyelinating syndromes, and meningovascular syndromes.3,6 Epidural abscess has been reported in less than 1.5 percent of the neurologic complications, and generally this is associated with spondylitis.3,4 Abscesses may arise from contiguity to spondylitis or from hematogenous spread. Brucellar spinal epidural abscesses commonly involve the lumbar spine, but cervical cases have recently been reported.5 Multidrug, prolonged treatment must be initiated quickly. One recommended regimen is doxycycline, rifampin (Rifadin), and trimetho-prim-sulfamethoxazole (Bactrim, Septra) for the course that clinical, serologic, or MRI activity persist.3 Clinical response usually is satisfactory and surgical decompression is unnecessary unless there is associated medullar compression. Although rare, Brucella infection should be considered in patients presenting with signs and symptoms of spinal epidural abscess, especially in those living or traveling to endemic areas and those in close contact with infected domesticated animals and/or meat and dairy products.

REFERENCES

1. Chao D, Nanda A. Spinal epidural abscess: a diagnostic challenge. Am Fam Physician. 2002;65:1341–6.

2. Bleck TP, Greenlee JE. Epidural abscess. In: Mandell GL, Douglas RG, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and practice of infectious diseases. 5th ed. Philadelphia: Churchill Livingstone;2000:1031–4.

3. Perez-Calvo J, Matamala C, Sanjoaquin I, Rodriguez-Benavente A, Ruiz-Laiglesia F, Bueno-Gomez J. Epidural abscess due to acute Brucella melitensis infection. Arch Intern Med. 1994;154:1410–1.

4. Solera J, Lozano E, Martinez-Alfaro E, Espinosa A, Castillejos ML, Abad L. Brucellar spondylitis: review of 35 cases and literature survey. Clin Infect Dis. 1999;29:1440–9.

5. Pina MA, Modrego PJ, Uroz JJ, Cobeta JC, Lerin FJ, Baiges JJ. Brucellar spinal epidural abscess of cervical location: report of four cases. Eur Neurol. 2001;45:249–53.

6. Young EJ. Brucella species. In: Mandell GL, Douglas RG, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's Principles and practice of infectious diseases. 5th ed. Philadelphia: Churchill Livingstone;2000:2386–92.

Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

Please include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

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