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He then developed large flank bruising bilaterally. CT of the abdomen revealed hyperdense thickening of the bilateral rectus abdominis muscles, consistent with bilateral rectus sheath hematomas. Early in his hospital stay, he developed abdominal distension and required a blood transfusion. Significant medications included aspirin and naproxen. He denied abdominal pain, fevers, melena, rectal bleeding, or hematemesis. His hematocrit was 23% with a positive fecal occult blood test. When patients with SDE must be managed medically, early identification of the causative organism to guide antibiotic choice and close monitoring in the inpatient setting for incident neurologic compromise and response to therapy are critical to reducing the morbidity and mortality associated with this rare condition.Īimee Wehber, MD Department of Internal Medicine, Graduate School of Medicine, University of Tennessee Medical Center, Knoxville, TN Kimberley Morris, MD Department of Internal Medicine, University of Tennessee Medical Center, Knoxville, TNĬase Presentation: An 80-year-old male presented with a 1-week history of weakness, lightheadedness, nausea, vomiting, and minor nonproductive cough. Outcomes of medical management for SDE are largely unknown.Ĭonclusion: Standard therapy for spinal SDE is emergent surgery and antibiotics, but situations may arise, such as with this patient, in which surgical risk outweighs its benefits, necessitating treatment with antibiotics alone. Surgical drainage followed by systemic antibiotics is the treatment of choice, but when surgery is contraindicated, patients may be treated with antibiotics alone. At 8-week follow-up, the patient remained neurologically intact with continued improvement in the extent of his SDE and scattered muscular abscesses.ĭiscussion: Spinal SDE is an extremely rare condition with high rates of morbidity and mortality. The patient remained stable without neurologic deficit and was transferred to a nursing facility for prolonged antibiotic therapy. Repeat MRI after 2 weeks demonstrated marked improvement in the lumbar SDE, with slight or no decrease in the SDE elsewhere.
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Blood, urine, and muscle abscess cultures were positive for methicillin-sensitive Staphylococcus aureus, and antibiotics were tailored to nafcillin, bactrim, and rifampin. Initial therapy included vancomycin, cefepime, metronidazole, bactrim, and rifampin. He was therefore treated with antibiotics alone. The patient, who at the time of admission was neurologically intact, was deemed a poor surgical candidate because his extensive SDE would require multilevel neurosurgical intervention that would place him at significant risk for spinal instability and neurologic compromise. CT of the back demonstrated multiple abscesses in the right iliopsoas, paraspinal, and abductor musculature MRI of the cervical, thoracic, and lumbar spine revealed extensive subdural empyema (SDE) filling the lumbar through cervical canal, as well as loculated fluid within the cauda equina region. Initial studies were significant for leukocytosis of 13,000 with 82% neutrophils opiates, tricyclics, and antidepressants on urine drug screen erythrocyte sedimentation rate of 58 and C-reactive protein of 235. On his arms and legs were scattered petechiae and track marks. Examination revealed a II/VI systolic murmur at the left lower sternal border, no nuchal rigidity, intact strength and reflexes, and normal perineal sensation and rectal tone. He was afebrile with elevated heart rate and blood pressure and was noted to be in moderate distress secondary to pain. Review of symptoms was positive for night sweats, anorexia, and intermittent difficulty voiding requiring self-catheterization. Rachel Apple, MD Internal Medicine and Pediatrics, Vanderbilt University, Nashville, TN Rosette Chakkalakal, MD, MHS Department of General Internal Medicine, Vanderbilt University, Nashville, TNĬase Presentation: A 48-year-old male with a history of intravenous drug use presented with 2 weeks of back pain radiating from his buttocks to his shoulders.