2019 Research Forum

Applicant: Phillip Aguìñiga-Navarrete RA Principal Investigator & Faculty Sponsor: Rachel O’Donnell MD Pediatric Paraspinal Abscess

Rachel O’Donnell MD, Sean Sayani MD, Daniel Quesada MD, Kieron Barkataki DO, Phillip Aguìñiga-Navarrete RA, Madison Garrett RA

INTRODUCTION Paraspinal Abscesses are rare in the pediatric population and diagnosis is often delayed due to non-specific symptoms. Etiology is usually due to invasive spinal procedures. Here we present a finding of a paraspinal abscess in a pediatric patient, with no identifiable risk factors. 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. DISCUSSION 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 in 100,000–250,000.1,2 Non-specific symptoms, especially in pediatrics, commonly lead to delayed identification causing worsening complications.3 The most common etiology are abscesses resulting from spinal procedures like lumbar punctures.2,3 Others include spread from: adjacent structures, or the hematogenous and lymphatic systems. Risk factors include diabetes mellitus, trauma, immunocompromised state, and intravenous drug use4. In regard to our case, no etiology or risk factors were identified. Often, they occur in the mid-thoracic and lumbar spine.3 The most prevalent bacteria is S. aureus, up to 79 percent in pediatric cases3. In terms of diagnosis, both C-Reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR) are both sensitive but not specific modalities. However, a normal White Blood cell count (WBC) does not exclude the diagnosis. Magnetic Resonance Imagining (MRI) is the gold standard due to its high sensitivity and specificity. CT imaging is used often due to accessibility and of lesser cost5. Management using parental antibiotics can be initially attempted for smaller abscesses. Larger abscesses might warrant percutaneous drainage. Surgical debridement should be considered with failure of conservative management, neurological signs, and spinal involvement.5 Ultimately, pediatric paraspinal abscesses should be kept in the differential in cases with unusual presentations of refusal to ambulate and abdominal pain. Early diagnosis can lead to a significant reduction in morbidity and mortality.

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

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