2019 Research Forum

Pediatric Paraspinal Abscess

Rachel O’Donnell 1 MD, Daniel Quesada 1 MD, Kieron Barkataki 1 DO, Sean Sayani 2 MD R3, Phillip Aguìñiga-Navarrete 3 RA, Madison Garrett 4 RA 1 UCLA Health Sciences, Clinical Instructor, Emergency Medicine, Kern Medical, Bakersfield, CA 2 PGY-III, Emergency Medicine, Kern Medical, Bakersfield, CA

3 Research Coordinator, Emergency Medicine, Kern Medical, Bakersfield, CA 4 Research Associate, Emergency Medicine, Kern Medical, Bakersfield, CA

Educational Merit Capsule What do we already know about this clinical entity? Paraspinal Abscess are rare in the pediatric population, and diagnosis is delayed due to non-specific symptoms . Etiology is usually due to invasive spinal procedures.

Case Presentation A 2-year-old female with no medical history presented to the Emergency Department with increasing refusal to ambulate, abdominal pain and fevers for four days. On exam, patient refused to bear weight on the right lower extremity. Labs showed a leukocytosis, lactic acidosis, elevated c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Computed Tomography (CT) of the abdomen and pelvis was significant for multiloculated fluid collections in the right lumbar paraspinal musculature extending from L1-L5 without spinal involvement (Image). She was initially given parenteral antibiotics and subsequently had percutaneous drainage performed. Cultures of the abscess grew S. aureus ; blood cultures were negative. The patient was ambulating and tolerating food one day after the procedure. Our case illustrates a rare presentation of an isolated pediatric paraspinal abscess. Due to its infrequency, prevalence is not well documented in North America. Within developing nations, incidence is 1:100,000– 250,000. 1,2 Non-specific symptoms, especially in pediatrics, commonly lead to delayed identification and subsequent morbidity. 3 The most common etiology is complication from spinal procedures like lumbar punctures. 2,3 Others include spread from adjacent structures or hematogenous and lymphatic systems. Often, they occur in the mid-thoracic and lumbar spine. 3 Risk factors include DM, trauma, immunocompromised state and IVDU. 4 As demonstrated in our case, no etiology or risk factors were identified. The most prevalent bacteria are S. aureus , identified in up to 79 percent of pediatric cases. 3 For diagnosis, CRP and ESR are sensitive but not specific modalities. A normal WBC count does not exclude diagnosis. MRI is the gold standard due to its high sensitivity and specificity. CT imaging is used frequently due to accessibility and lesser cost. 5 Management using parenteral antibiotics can be initially attempted for smaller abscesses. Larger abscesses may warrant percutaneous drainage. Surgical debridement should be considered with failure of conservative management, neurological signs and spinal involvement. 5 Discussion

Case Imaging

What is the major impact of the image?

Demonstration of rare finding of a paraspinal abscess in a pediatric patient, with no identifiable risk factors.

How might this improve emergency medicine practice?

Broadening the differential of pediatric patients presenting with non-specific symptoms. Promoting early identification and hopefully preventing associated morbidity/mortality

References

Image. Axial computed tomography of the lumbar spine revealing a paraspinal abscess (arrow). No involvement of the vertebrae or spinal canal is observed.

1. Sharma RR, Sethu AU, Mahapatra AK, et al. Neonatal Cervical Osteomyelitis with Paraspinal Abscess and Erb’s Palsy. Pediatr Neurosurg . 2000 May;32(5):230–3. 2. Acharya U. A case of atypical presentation of thoracic osteomyelitis & paraspinal abscess. Mcgill J Med . 2008;11(2):164–7. 3. Kiymaz N and Demir Ö. Spontaneous cervical paraspinal and epidural giant abscess in a child— case report–. Neurol Med Chir . 2005 Oct;45(10):540–2. 4. Chen CT, Lin JC, Chang SY. Cough syncope induced by paraspinal abscess . Am J Med Sci. 2014 Jan;347(1): 86–7. 5. Lener S, Hartmann S, Barbagallo GMV, et al. Management of spinal infection: a review of the literature. Acta Neurochir (Wien) . 2018 Mar;160(3):487–496.

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