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Intramedullary spinal cord abscess associated with right-to-left shunt via right superior vena cava draining into
Satoshi Hirose1, Naohiro Sudo2, Masahiro Okada2
1Division of Neurology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan.
Rationale:
Intramedullary spinal cord abscess (ISCA) is a rare but treatable bacterial infection of the central nervous system, and the etiology in no less than 40% of the cases is cryptogenic. Although a few cases of ISCA in individuals with a right-to-left shunt (RL shunt) have been reported, only few arguments focused on the association between RL shunt and ISCA have been provoked. The right superior vena cava (RSVC) draining into the left atrium (LA) is an uncommon systemic venous anomaly that results in an RL shunt, and this anomaly causes several types of neurological complication such as stroke or brain abscess. We report the first case of ISCA associated with RSVC-LA RL shunt.
Patient Concerns:
A 36-year-old man developed progressive paraparesis, dysuria, and spontaneous pain in the lumbar region and lower extremities. Spinal magnetic resonance imaging revealed an intramedullary lesion extended from Th12 to L2 with ring-shaped gadolinium enhancement. Cerebrospinal fluid (CSF) study exhibited a marked pleocytosis, and CSF culture grew Streptococcus intermedius. Cardiovascular computed tomography angiography identified RSVC-LA RL shunt, which caused transient acute cardiac syndrome due to air embolus.
Diagnoses:
The patient was diagnosed with ISCA associated with an RSVC-LA RL shunt.
Interventions:
The patient was treated with a combination of intravenous administration of meropenem and vancomycin in a daily dose of 6 and 2.5 g, respectively, followed by intravenous administration of ampicillin in a daily dose of 750 mg. The intravenous antibiotic therapy was continued for 37 days.
Outcomes:
A favorable neurological outcome was obtained by the intravenous antibiotic therapy, and recurrence of infection was prevented by continuous oral antibiotic therapy for 18 months.
Lessons:
With a literature review of ISCA associated with RL shunt, we insist that screening for RSVC-LA is beneficial to patients who are diagnosed with cryptogenic ISCA as its identification leads to appropriate preventive therapy.
Insights
Intramedullary spinal cord abscess (ISCA) is rare, often cryptogenic. This case highlights a right superior vena cava draining into the left atrium (RSVC-LA) right-to-left shunt as a potential cause, emphasizing screening for this anomaly in cryptogenic ISCA.
Area of Science:
- Neurology
- Cardiology
- Infectious Disease
Background:
- Intramedullary spinal cord abscess (ISCA) is a rare central nervous system infection, with over 40% of cases having an unknown etiology (cryptogenic).
- Right-to-left (RL) shunts are known causes of neurological complications like stroke and brain abscess.
- Right superior vena cava draining into the left atrium (RSVC-LA) is an uncommon anomaly resulting in an RL shunt.
Observation:
- A 36-year-old male presented with progressive paraparesis, dysuria, and spinal pain.
- Spinal MRI revealed an enhancing intramedullary lesion from Th12 to L2.
- Cerebrospinal fluid analysis showed pleocytosis, and culture identified Streptococcus intermedius.
Findings:
- Cardiovascular CT angiography diagnosed an RSVC-LA RL shunt, which had previously caused transient acute cardiac syndrome due to air embolus.
- The patient was diagnosed with ISCA associated with the RSVC-LA RL shunt.
- Treatment involved 37 days of intravenous antibiotics (meropenem, vancomycin, ampicillin), followed by 18 months of oral antibiotics, leading to a favorable neurological outcome and preventing recurrence.
Implications:
- This case is the first reported instance of ISCA associated with an RSVC-LA RL shunt.
- Screening for RSVC-LA is recommended for patients with cryptogenic ISCA to enable targeted preventive strategies.
- Identifying and managing RL shunts can prevent serious neurological complications such as ISCA.
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