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|LETTER TO EDITOR
|Year : 2013 | Volume
| Issue : 3 | Page : 322-324
Metachronous occurrence of an intramedullary abscess following radical excision of a cervical intramedullary pilocytic astrocytoma
Sumit Thakar, Arun Rao, Dilip Mohan, Alangar Hegde
Department of Neurosurgery, SSSIHMS, Whitefield, Bangalore, India
|Date of Submission||26-Apr-2013|
|Date of Decision||28-Apr-2013|
|Date of Acceptance||30-May-2013|
|Date of Web Publication||16-Jul-2013|
Department of Neurosurgery, SSSIHMS, Whitefield, Bangalore
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Thakar S, Rao A, Mohan D, Hegde A. Metachronous occurrence of an intramedullary abscess following radical excision of a cervical intramedullary pilocytic astrocytoma. Neurol India 2013;61:322-4
|How to cite this URL:|
Thakar S, Rao A, Mohan D, Hegde A. Metachronous occurrence of an intramedullary abscess following radical excision of a cervical intramedullary pilocytic astrocytoma. Neurol India [serial online] 2013 [cited 2019 Sep 20];61:322-4. Available from: http://www.neurologyindia.com/text.asp?2013/61/3/322/115089
While the occurrence of spinal intramedullary abscesses is unusual,  their concomitant association with tumours is still rarer. The spinal tumours commonly associated with suppuration are dermoids and epidermoids,  while intramedullary lesions like low grade glioma  and ependymoma  are of anecdotal significance. We report the first case of an intramedullary cervical cord abscess occurring metachronously at the site of a radically excised intramedullary pilocytic astrocytoma.
A 45-year-old diabetic lady presented with high grade fever, neck pain, paresthesias in all limbs, decreased sensation in the trunk, rapidly progressive lower limb weakness and bladder incontinence of 2 weeks duration. On examination, the febrile patient demonstrated spastic paraparesis (grade 3-4/5), dissociated sensory loss from C7-T4 and exaggerated deep tendon reflexes in the lower limbs. There were no signs of meningeal irritation. Investigations revealed elevated sugars and total leukocyte counts, impaired renal parameters and urinary tract infection (UTI) with Escherichia More Details coli. Review of her first magnetic resonance imaging (MRI) showed a heterogeneously enhancing intramedullary lesion from C2-6 levels [Figure 1]a, expanding the cord [Figure 1]b and demonstrating significant T2-weighted change in the cord [Figure 1]c. Postoperative MRI had showed radical excision of the lesion [Figure 1]d. MRI at this admission showed a brilliantly enhancing intramedullary lesion at C5,6 levels [Figure 2]a expanding the cord [Figure 2]b with surrounding cord edema and swelling [Figure 2]c. The diagnosis of a recurrent intramedullary pilocytic astrocytoma was made, and she was advised re-exploratory surgery once her medical condition stabilized.
|Figure 1: (a) Gadolinium enhanced T1 weighted MR image, sagittal section of the cervico-thoracic spine, showing a heterogeneously enhancing intramedullary lesion extending from C2 to C6. (b) Gadolinium enhanced T1 weighted image (WI), axial section, showing the cord expanded by the lesion. (c) T2 WI, sagittal section of the cervicothoracic spine, showing the lesion- associated hyperintensity from C2 to C7. (d) Post-operative Gadolinium enhanced T1 WI, sagittal section showing no residual enhancing lesion|
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|Figure 2: (a) Gadolinium enhanced T1 weighted MR image, sagittal section of the cervico-thoracic spine, showing an enhancing intramedullary lesion at C5, C6 levels. (b) Gadolinium enhanced T1 weighted image (WI), axial section, showing the cord expanded by the lesion. (c) T2 WI, sagittal section of the cervicothoracic spine, showing the lesion- associated hyperintensity from C5 to C7. Follow-up Gadolinium enhanced MRI: (d) sagittal section and (e) axial section, showing resolution of the lesion. (f) T2 WI, sagittal section, showing resolving cord edema|
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She was managed elsewhere by a physician for two weeks with appropriate antibiotics for UTI-related sepsis and other general measures for a diabetic nephropathy. Her blood culture remained sterile. On readmission at this facility, a repeat MRI was done as she had subjective improvement in her sensory symptoms. The MRI showed complete resolution of the lesion with no residual enhancement [Figure 2]d and e and resolving cord edema [Figure 2]f. The diagnosis of a recurrent intramedullary pilocytic astrocytoma was revised to that of a sepsis-related intramedullary abscess that resolved concomitantly with the resolution of the systemic infection. She was discharged on oral Cefuroxime (based on the sensitivity pattern of the urinary culture report) for a month. One month later, after 6 weeks of antibiotic therapy, she showed improvement in her spasticity and sensory deficits, while her motor strength and bladder dysfunction remained the same.
Rapidly progressive neurological deficit in a septicemic patient with a spinal tumour should always alert the physician to an underlying suppuration or to an intratumoural bleed. The use of steroids in such patients generally aggravates the infective process. In a significant number of patients, no primary source of infection can be found, , while in others, the detected primary sources may be blood stream, trauma-related, or due to contiguous spread.  Neurological outcome even after radical surgery and antibiotics is generally dismal. 
In the previously reported cases of intramedullary tumour related abscesses, , the suppurative process had occurred synchronously in two patients, and a few months later in the other patient with a persisting syrinx.  The location of the lesions was thoracic in all the patients. Cord ischemia or stasis of the syrinx fluid favouring bacterial colonization was the postulated mechanism for abscess formation. The unique features in our patient include: cervical location, a remote occurrence on a long-term follow-up, and the histopathology of the primary tumour. As a radiological differential, one may contend that the lesion could have been demyelination that resolved spontaneously. In the absence of any contributory clinical features and negative imaging of the rest of the spine and brain, this possibility was unlikely. The clinical presentation in a setting of systemic infection favoured a retrospective diagnosis of an abscess. It is possible that bacterial colonization occurred in the inferior most portion of the excision cavity.
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[Figure 1], [Figure 2]