Abstract
The five year old, somnolent girl from Mozambique with no medical history was presented with fever, neckstiffness, headaches, an almost complete paraplegia and a septic picture. Malaria parasites and HIV testing was negative. The lumbal puncture revealed staphylococcus. Subsequently a MRI scan showed no sign of meningitis but an extensive posterior epidural collection from C3 to the level of S1. Moreover it showed a vertebral osteomyelitis at L1. Bacteria in CSF were seen as an artefact and the child was treated by multilevel (purely) epidural punctures with drainage, rinsing and instillation of ceftriaxon. The epidural puncture proved acid fast bacilli in the pus, so that an anti-tuberculotic therapy was given. The child recovered quickly from sepsis and was able to walk several steps without help after three months.
1. Clinical History
A five-year-old, somnolent girl from a rural region in Mozambique was brought to our hospital in Malawi by her mother. She presented with fever, tachypnoea, tachycardia, a relatively low blood pressure (which was difficult to measure due to a lack of correctly sized pressure cuffs), neckstiffness, headaches and intense back pain at the level L1). On physical examination the child showed an almost complete paraplegia of the inferior limbs with loss of sensation and incontinence.
The girl had no medical history and her mother did not remember a trauma, an accident with a dog, a snakebite or any form of traditional treatment.
A full blood count demonstrated leucocytosis and anaemia. Malaria parasites and HIV testing were negative A lumbal puncture was initiated. Our setting in a resource poor country makes it impossible to do a CT or an MRI before the LP in order to exclude a raised intracranial pressure. The LP showed a turbid cerebro spinal fluid. A turbid spinal fluid usually is due to a mixture of bacterial and cellular debris with a huge amount of leucocytes. This turbid CSF than is very much an indicator of an acute bacterial meningitis. The culture of the CSF revealed Staphylococcus aureus.
Leucocytosis, tachycardia, tachypnoe and a reduced GCS, together with fever and a borderline bloodpressure constitute the diagnosis of a systemic inflammatory response syndrome in our patient. The additional finding of Staphylococcus aureus in the pus as source for the SIRS defines the diagnosis of an SIRS through infection, commonly called sepsis.
Our clinical problem now was, that a paraplegia with sensory loss and incontinence did not fit to the diagnosis of meningitis. In meningitis we should expect a hemiplegic picture. Due to this problem we decided to make use of our scarce resources and initiated a MRI scan.
2. Imaging
A MRI of the vertebral column showed no signs of meningitis but an extensive posterior epidural collection of fluid from C3 to the level of S1 with two suspicious structures, appearing like abscesses on the level Th12/L1 (Figures 1 and 2).
Figure 1 shows a sagittal, T2-weighted MRI, where there is a high-intensity signal parallel to the spinal cord. Proofed by aspiration this was an epidural collection of pus from the cervical to the sacral spinal cord (exactly: C3 to S1). There were additional pockets of pus on two levels (Th12/L1).