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Purpose Congenital dermal sinuses are a rare form of spinal dysraphism. The developmental defects are located along the midline neuroaxis, with sinuses in the cervical region being the least common. Congenital dermal sinuses can be associated with intraspinal infection as they act as a direct route from the skin and subcutaneous tissues into the spinal cord. Methods The authors present two cases of cervical dermal sinuses complicated by intramedullary abscess. Both children presented with neurological decline and febrile illness. MRI showed intraspinal abscess. Both underwent prompt surgical excision of the sinus tract, exploration of the cord and intravenous antibiotics. Results Both patients demonstrated excellent neurological recovery. Conclusions Complete surgical excision of the sinus and tract in addition to long-term antimicrobials can yield excellent neurological outcomes. At surgery, do not expect to find pus when exploring the intramedullary component. Long-term follow-up is advocated due to potential late recurrence.

Intramedullary spinal cord abscess (ISCA) is a rare infection of the central nervous system. Untreated, it may result in significant morbidity and mortality. We describe the case of a 34-year-old man, who initially was admitted for bacterial meningitis. 3 days after initiation of antibiotic therapy, a gradually and progressive weakness appeared on the left side of his body with numbness on the contralateral side. MRI of the spine demonstrated an ISCA at level of C4. A myelotomy and surgical drainage was performed. Postoperatively, the patient had improved significantly his neurological deficit. ISCA is still a life-threatening condition, we point out that the diagnosis should be highly suspected, if a cystic spinal cord lesion is surrounded by significant medullar edema associated with fast onset of symptoms, especially in a context of sepsis or acuate meningitis. Prompt surgical evacuation followed by adequate antibiotic therapy, are the mainstays of treatment.

BACKGROUNDThe purpose of the present case report is to highlight the presentation, workup, clinical decision making, and operative intervention for a 68-year-old woman who developed rapidly progressive myelopathy secondary to idiopathic cervical intramedullary abscess.OBSERVATIONSThe patient underwent laminectomy and aspiration/biopsy of the lesion. Intraoperatively, division of the posterior median sulcus released a large volume of purulent material growing the oral pathogens Eikenella corrodens and Gemella morbillorum. Broad-spectrum antibiotics were initiated postoperatively. At the 6-month follow-up, the patient had almost completely recovered with some persistent hand dysesthesia. Complete infectious workup, including full dental assessment and an echocardiogram, failed to reveal the source of her infection.LESSONSThe authors report the first case of cryptogenic spinal intramedullary abscess secondary to Eikenella spp. and Gemella spp. coinfection. Intramedullary abscesses are exceptionally rare and most commonly develop in children with dermal sinus malformations or in the context of immunosuppression. In adults without risk factors, they can readily be mistaken for more common pathologies in this age group, such as intramedullary neoplasms or demyelinating disease. Prompt diagnosis and management based on rapidly progressive myelopathy, assessment of infectious risk factors and/or symptoms, and targeted imaging are critical to avoid potentially devastating neurological sequelae.

Cervical intramedullary spinal cord abscess is an extremely rare entity. We present a case of a 53-year-old male with a cervical intramedullary spinal cord abscess caused by Streptococcus viridians that presented with 4 days of neck pain and progressive left upper extremity numbness and weakness. The patient was managed with a cervical myelotomy and adjunctive antibiotic treatment.

La tuberculose du système nerveux central est une affection rare. Elle se présente sous plusieurs formes mais l'association d'un abcès intra médullaire et un pott multifocal est exceptionnelle. Nous rapportons le cas d'une patiente âgée de 23 ans chez qui le diagnostic d'un pott multifocal L2-L3 et L4-L5 a été posé sur la tomodensitométrie (TDM) du rachis. Elle a été mise sous traitement anti tuberculeux et devant l'installation d'un tableau de compression médullaire deux mois après le début du traitement, une imagerie par résonance magnétique (IRM) médullaire a été réalisée objectivant une image d'abcès intra médullaire à hauteur de T4. Elle a été opérée bénéficiant dans le même temps opératoire du drainage de l'abcès intra médullaire et de la stabilisation du rachis. L'évolution a été favorable, la patiente a été suivie pendant 12 mois. L'association d'un abcès intra médullaire et un pott multifocal est exceptionnelle. Le traitement repose sur les antituberculeux et la chirurgie pour lever la compression médullaire et ou stabiliser le rachis le cas échéant.

Background Intramedullary abscess of the spinal cord (IASC) symptoms are often nonspecific with the diagnosis rarely considered on the initial differential. This can delay surgical management and may lead to permanent neurological deficits or mortality. Additionally, many organisms are implicated in IASC, leading to uncertainty in empiric antimicrobial therapy. Methods This case report follows a patient with IASC due to Streptococcus anginosus group (SAG). We also review a 25-case meta-analysis of IASC and 5 cases of SAG IASC. Results A 65-year-old woman with an unremarkable past medical history presented with 2 weeks of neck pain and paresthesias. She was afebrile with no systemic signs of infection or abnormal laboratory markers. MRI revealed an 8mm lesion at C4-C5 with edema C1-T1 and she received high-dose steroids for suspected malignancy. Follow-up MRI 4 days later revealed rapid progression of the lesion to 14mm, consistent with an infectious process (Figure 1). The patient received empiric therapy with ceftriaxone, vancomycin, and metronidazole. She underwent a C2-C7 laminectomy with midline myelotomy for evacuation of the abscess. Due to clinical and radiographic progression she required a second surgical wash-out 4 days later. Her intraoperative cultures grew SAG and her regimen was changed to penicillin and vancomycin. Her course was complicated by eosinophilia requiring meropenem and later linezolid to complete a 6-week course, during which she improved clinically and neurologically. Our review demonstrated that 40% of cases presented with fever. The majority of cases were idiopathic with the organisms known in 70% of cases. Surgery and IV antibiotics were used in 83% of cases and one case required a second surgery. A wide range of antibiotic regimens were reported with no consensus on how to best preserve neurological function. Conclusion This case highlights the complexities in diagnosing and managing IASC. We suspect that due to the protected nature of the intramedullary space, the infection may not trigger constitutional symptoms or a systemic inflammatory response. In patients who present with significant neurological deficits, MRI may reveal IASC and this should prompt immediate initiation of antibiotics that penetrate the blood–brain barrier and surgical intervention. Disclosures All authors: No reported disclosures.

Congenital dermal sinus (CDS) is a type of occult spinal dysraphism characterized by a midline skin dimple. A 12-month-old girl presented with fever and ascending quadriparesis. She had a midline skin dimple in the upper sacral area that had been discovered in her neonatal period. Imaging studies revealed a holocord intramedullary abscess and CDS. Overlooking CDS or misdiagnosing it as benign sacrococcygeal dimple may lead to catastrophic infection and cause serious neurological deficits. Therefore, further imaging work-up or consultation with a pediatric neurosurgeon is recommended following discovery of any atypical-looking dimples in the midline.

Spinal abscess in pediatric age group is a rare entity. Tubercular type is even rarer and it has been found to be associated with patent dermal sinus. Very few cases have been reported so far.We present a 2-month-old baby with gradually progressing paraparesis. There was a small dermal sinus in the lower area of right buttock which was discharging pus. MRI was done which showed intramedullary fluid collection at the level of lower lumbar and sacral spine suggesting abscess formation. Patient party was suggested for surgical exploration and histopathological evaluation. However, they denied and thus baby was put on steroid therapy. The baby gradually improved. However he started having paraparesis again and even worse than before. Repeat MRI showed intramedullary collection more than the previous MRI. Again surgical option was given and finally surgery done. Right hemilaminectomy was done from L3-4-5-S1and dura exposed. Dura was incised and spinal cord, conus and cauda equina exposed which were swollen and congested. Midline myelotomy was done opening the intramedullary. Free flow of thick pus was observed. Dermal sinus was excised and closed.Pus and small pieces of granulation tissue was sent for culture and cytological examination which showed features of tuberculosis. Antitubercular treatment was started and the baby became much better.Nepal Journal of Neuroscience 12:43-45, 2015

Intramedullary abscess is a rare condition with high rate of mortality and morbidity. We are presenting a case of delayed intramedullary abscess in an operated case of spinal lipoma, after 2 years of primary surgery. To best of our knowledge this only second case of intramedullary abscess in a case of spinal lipoma without dermal sinus.

A spinal intramedullary abscess secondary to an infected dermoid cyst is rare, and it has a poor prognosis, unless diagnosed and treated promptly. We report a 12-month-old patient with a spinal intramedullary abscess with secondary to a dermoid cyst resulting from a dermal sinus, despite a clearly defined opening at the lower back with discharge of a purulent material from a dermal sinus tract seen on the lower back before the patient had become symptomatic and showed meningeal signs. The patient was managed as a case of meningitis until he had complications that endangered his life, and then further radiological evaluation was done to delineate the underlying pathology. This case illustrates the importance of the recognition and evaluation of skin markers because of the potential for intradural extension and a frequent association with other dysraphic abnormalities. It also emphasizes the importance of early diagnosis and treatment of spinal intramedullary abscess.

Bacterial meningitis is rarely complicated by an intradural spinal abscess, and recurrent meningitis is an uncommon presentation of a spinal intramedullary abscess. Here, we report a 63-year-old patient with recurrent meningitis as the first manifestation of an underlying spinal intramedullary abscess. To the best of our knowledge, no previous report has been issued on recurrent meningitis accompanied by a spinal intramedullary abscess in an adult. In this article, the pathophysiological mechanism of this uncommon entity is discussed and the relevant literature reviewed.

Study design: A rare case of a holocord intramedullary abscess with review of literature. Objectives: Summary of clinical presentation, radiology, microbiology, etiology and management of intramedullary spinal cord abscess. Abscess involving the entire spinal cord is extremely rare and awareness of such an event could avoid delay in evacuation of the absess. Methods: The incidence, clinical presentation, radiological investigations, treatment and etiology of intramedullary spinal cord abscess in 100 consecutive cases are discussed. Results: Intramedullary spinal cord abscesses are rare. Presently, only five cases of holocord intramedullary abscess are described. In our analysis of 100 cases of intramedullary abscess, a male preponderance was found. The first and the third decades were the most common age groups. Prognosis is poor if treatment is delayed. Contrast-enhanced MRI is the ideal investigation for diagnosis. Prompt surgical drainage of the abscess with appropriate antibiotic therapy is mandatory since the natural course of the disease has a very unfavourable outcome. Staphylococcus and Streptococcus were the most common causative organisms. Conclusion: Intramedullary spinal cord abscess along the entire length of spinal cord is rare. A thorough history with precise clinical localisation, a high index of suspicion, contrast-enhanced MRI at appropriate level and prompt surgical drainage with appropriate antibiotic therapy are key to the eventual outcome and prognosis.

La enfermedad de Rendu-Osler-Weber es una enfermedad autosómica dominante que se manifiesta por telangiectasias en piel y mucosas y malformaciones arteriovenosas en diversos órganos. El compromiso neurológico puede ocurrir por la presencia de malformaciones arterio-venosas cerebrales, hemorragia intracraneal, y más habitualmente por accidentes cerebrovasculares isquémicos y abscesos cerebrales secundarios a embolia paradojal, en pacientes con malformaciones arteriovenosas pulmonares. El absceso intramedular es una entidad rara, inusual como complicación de la enfermedad de Rendu-Osler-Weber. Presentamos el caso de una mujer de 56 años de edad, con antecedentes familiares de enfermedad de Rendu-Osler- Weber, que ingresó a Terapia Intensiva con cuadriplejia aguda e hipoxemia, en quien se diagnosticó fístulas arteriovenosas pulmonares y un absceso intramedular cervical.Rendu-Osler-Weber syndrome is an autosomal dominant disorder characterized by multiple skin and mucosal telangiectasis and multiorgan arteriovenous malformations. Neurological manifestations may occur because of cerebral arteriovenous malformations, intracranial hemorrhage, and most commonly by ischemic stroke and brain abscess secondary to paradoxical embolization in patients with pulmonary arteriovenous malformations. Intramedullary abscess is a rare, unusual condition, in Rendu-Osler-Weber syndrome. We report the case of a 56 years old woman, with a familial history of Rendu-Osler-Weber syndrome, admitted to intensive care with acute quadriplegia and hypoxemia. Our diagnosis was pulmonary arteriovenous malformations and intramedullary abscess.

Penetrating spinal injuries by wooden foreign body (WFB) is rare 1 . We present a 52 year-old man with a cervical spine injury by a WFB, identified 172 days after the accident, with an intramedullary abscess. Surgical intervention and antibiotic treatment led to neurological improvement.

Intramedullary spinal cord abscess secondary to dorsal dermal sinus is a rare entity and involvement of the entire length of spinal cord is even rarer. A thorough history with precise clinical localization, a high index of suspicion, Magnetic Resonance Imaging (MRI) of spine and prompt surgical drainage with appropriate antibiotic therapy are key to the eventual outcome and prognosis.

We report two unusual cases of a 17-month-old boy with a previously undiagnosed lumbar dermal sinus tract terminating in an intradural dermoid cyst and holocord edema or syrinx, presenting with paraparesis and sphincter dysfunction secondary to an intramedullary abscess and a 26-month-old boy with a previously undiagnosed lumbar dermal sinus tract terminating in an infected dermoid cyst and intramedullary abscess, presenting with recurrent episodes of meningitis and hydrocephalus. Pre-operative magnetic resonance imaging (MRI) studies in these patients were initially confused for an intramedullary spinal cord tumor; however, the presence of an associated dermal sinus tract made this diagnosis of neoplasm less likely. Total excision of the dermal sinus tract, debulking of the dermoid cyst and drainage of the intramedullary abscess through an L1-L5 osteoplastic laminoplasty and midline myelotomy, followed by long-term antibiotic therapy resulted in a good functional recovery. Post-operative MRI of the spine showed removal of the dermoid cyst, decreased inflammatory granulation tissue and resolution of the holocord edema or syrinx. We also performed a literature review to determine the cumulative experience of management of intramedullary abscess in this rare clinical setting.