Introduction
Spinal epidural abscesses (SEA) are frequently misdiagnosed and the delays in diagnosis can result in significant morbidity and mortality.1 There are very few cases reported in pregnancy. We present a case of a multiparous 34-year-old woman with a complex medical and obstetric background with an SEA.
Case
A 34-year-old G6P2+1 with an obstetric history of one vaginal delivery, one elective caesarean for DCDA twins and three elective terminations presented to the Emergency Department at 30 weeks gestation with severe back pain radiating through her chest with pleuritic pain, tachycardia, fever and hypertension with an elevated white cell count (18.6x109/L) and CRP (103.9mg/L) . Her medical history included previous intravenous drug use, Hepatitis C, fatty liver disease, systemic lupus erythematosis and recent methicillin-sensitive staphylococcus aureus (MSSA) infective endocarditis with cardiomyopathy. She was treated presumptively for sepsis of unknown origin and pulmonary embolism (PE) and transferred to ICU.
VQ scan was negative for PE. MRI 4 days from admission showed posterior epidural abscess at T2-T4 level with moderate spinal canal stenosis, left T3-T4 facet joint effusion consistent with septic arthritis and adjacent soft tissue inflammation. Transoesophageal echo showed moderate LV dysfunction and incidental cephalic and internal jugular vein thrombus but did not demonstrate endocarditis. Microbiological investigations indicated an MSSA bacteraemia.
Dental assessment demonstrated grossly carious dentition. Five teeth were extracted and she was treated with 6 weeks of IV flucloxacillin and therapeutic enoxaparin and responded well. Repeat imaging showed complete resolution of the SEA and associated septic arthritis.
Elective repeat caesarean section with bilateral salpingectomy was carried out at 38+5 weeks, a male infant (2963g, 21st centile) was delivered. She was discharged on 6 weeks of oral flucloxacillin with infectious diseases follow-up, and on 12 weeks of therapeutic enoxaparin.
Discussion
This case emphasises the complexity of diagnosis of SEA in pregnancy particularly in women with multiple confounding medical comorbidities. Pregnancy may delay a diagnosis but the physiological changes may result in more complications than non- pregnant SEA.
References