Corresponding author. Corresponding author: Mi-Woon Kim, M. Tel: , Fax: , moc. This article has been cited by other articles in PMC. The cause of the high protein content of the spinal fluid is meningeal irritation and inflammation.
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Corresponding author. We read with interest the article by Zimmerer et al. At the outset we would like to congratulate the authors on the thorough and concise review of this uncommon condition. As noted by the authors, SEA is found in 0. Further as seen in the study, patients oftentimes present with non-specific back pain thus making the diagnosis difficult.
The severity and the location of weakness depend on the location of the abscess; with the most common site being thoracolumbar region [ 3 ].
MRI spine with and without wwo contrast is the diagnostic modality of choice with all patients in the study being diagnosed by it [ 1 ]. However in early stages of SEA, MRI can remain inconclusive [ 4 ] and due to spinal shock, patient can be hyporeflexic and a sensory level might not yet have been formed.
An MRI of the thoracolumbar spine wwo contrast done at the onset of symptoms was non-contributory. Upon admission he was paraplegic with absent knee and ankle reflexes, plantar responses were mute and a sensory level could not be established. He had urinary retention. He was afebrile but confounding the picture, he had a bowel perforation, which required emergent surgical repair. Based on the clinical and radiological findings, a working diagnosis of GBS was made.
Repeat emergent MRI wwo of the entire spine showed extensive cervicothoracic epidural abscess with infarction of the thoracic cord. Patient underwent emergent open decompression and drainage of the abscess.
It is interesting to note that study had four patients with primary SEAs and three with secondary SEAs where an oral focus was thought to be the cause, although only one of the primary SEAs had similar pathogen as the oral one [ 1 ]. The only concern is whether a thorough search was made to identify other foci of infection. In our own case, we initially thought the bowel perforation as the source of infection but upon a more careful physical examination, patient had otitis externa, which we believe was the source of infection based on culture of the specimen.
In conclusion, we would like to re-emphasize that SEAs can have protean manifestations and a high index of clinical suspicion especially when imaging remains inconclusive and a thorough systematic review is necessary in its diagnosis. Acknowledgments The authors have no financial disclosure.
The authors disclose no conflicts of interest. Conflict of interest None. Zimmerer et al. References 1. Neurosurgical care of spinal epidural, subdural, and intramedullary abscesses and arachnoiditis.
Orthop Clin North Am. Spinal epidural abscess: the importance of early diagnosis and treatment. J Neurol Neurosurg Psychiatry. Spinal epidural abscess: evaluation of factors influencing outcome.
Meningeal infiltration of malignant lymphoma presenting with Froin's syndrome.
Froin’s syndrome: an uncommon mimicker of Guillain–Barre syndrome
Pseudo-Froin's syndrome, xanthochromia with high protein level of cerebrospinal fluid