Written informed consent was obtained from the patient and his family for publication of this case report and accompanying images.
An 81-year-old man (height, 175 cm; weight, 85 kg) visited the emergency department with bilateral leg weakness, which led to difficulty in knee flexion 3 days before. He also developed fever and experienced back pain for approximately 1 week. Earlier, he had been walking with the assistance of a walker. He reported a history of aortic valve replacement surgery, mitral valvuloplasty, and tricuspid valvuloplasty, in addition to a history of heart failure, atrial fibrillation, obstructive arteriosclerosis, diabetes, chronic obstructive pulmonary disease, spinal canal stenosis, and dementia. Therefore, his general health condition was deemed poor. He was taking aspirin, apixaban, furosemide, spironolactone, and insulin. Echocardiography showed poor wall motion with an ejection fraction of 41% and pulmonary hypertension (65/13 mmHg).
We were unable to obtain detailed information regarding neurological symptoms such as sensory disturbance and movement disorder because of the severe dementia. He could not flex his right knee, although he could briefly flex his left knee in the supine position. He also complained of severe back pain (face rating scale [FRS] = 4) at rest, which increased with body movement (FRS = 5). Except for an elevated temperature (38.0 °C), his vital signs were stable. Blood examination revealed a slight increase in C-reactive protein (3.64 mg/dl) and white blood cell count (10,300/μl).
Magnetic resonance imaging (MRI) showed extensive fluid retention in the spinal epidural space (Th6 to L3) and compression of the spinal cord (Th6/7, Th11/12, L2/3) (Fig. 1). The latter suggested paraplegia due to an epidural abscess. We performed emergency drainage using fluoroscopy-guided percutaneous puncture. The patient was placed in the prone position and received local anesthesia, following which any abscess near Th6/7, Th11/12, and L2/3 was punctured using a 14 G Tuohy needle under fluoroscopic guidance. Approximately 3 ml of purulent discharge was drained from the Th6/7 and L2/3 levels, and approximately 4 ml of a clear, light-yellow colored discharge was drained from the Th11/12 level. For involved areas near Th6/7, two needles were placed at the Th6/7 and Th8/9 levels, respectively. A 5-Fr catheter was placed under fluoroscopic guidance using a guide wire, followed by perfusion with saline until apparent removal of the corpuscles. MRI performed 1 day later showed relief from the compression due to the abscess. Three weeks later, the abscess had completely disappeared (Fig. 2).
At the time of admission, provisional treatment with meropenem, clindamycin, and vancomycin was initiated and continued for 3 days. The prescription was de-escalated to cefazolin and clindamycin after group G streptococcus was detected in the abscess, and the treatment was continued for 28 days. Blood cultures were negative. Pain on movement (FRS = 2) reduced after the drainage procedure, while pain at rest also improved (FRS = 1) after 3 days. The muscle weakness gradually resolved, and he could walk to a portable toilet without assistance 20 days after the procedure. He was discharged to a nursing home for the elderly on the 57th day.
