Spinal epidural abscess differential diagnosis

Spinal epidural abscess should be considered in any patient with backache, fever, and spine tenderness, 1) especially diabetics, IV drug abusers or immunocompromised patients.

1. meningitis

2. acute transverse myelitis (paralysis is usually more rapid, radiographic studies are normal)

3. intervertebral disc herniation

4. spinal cord tumors. Consider malignancy in the differential diagnosis, and carefully examine surgical specimens in revision surgery 2).

5. post-op SEA may appear similar to pseudomeningocele 3).

Langerhans cell histiocytosis (LCH) could be considered as a possible diagnosis when a patient presents with features of infectious spondylitis with vertebral involvement 4).

A case of a 21-year-old woman presenting with quadriplegia which was initially diagnosed with an epidural abscess in view of her MR scan and raised inflammatory marker levels. Histology revealed an epidural extra-osseous Ewing's sarcoma (EES). Epidural location of EES is a very rare condition which can be very challenging to diagnose. Early diagnosis and surgical excision followed by chemotherapy represent the main stem of management 5).

1)
Heusner AP. Nontuberculous Spinal Epidural Infections. N Engl J Med. 1948; 239:845–854
2)
Wang SJ, Cao DL, Xu HW, Zhao WD, Hu T, Wu DS. Development of Primary Diffuse Large B-cell Lymphoma around an Internal Fixation Implant after Lumbar Fusion Surgery: A Case Report and Review of the Literature. World Neurosurg. 2020 Feb 5. pii: S1878-8750(20)30245-X. doi: 10.1016/j.wneu.2020.01.227. [Epub ahead of print] PubMed PMID: 32035201.
3)
Spiegelmann R, Findler G, Faibel M, et al. Postoperative Spinal Epidural Empyema: Clinical and Computed Tomography Features. Spin e. 1991; 16:1146–1149
4)
Lim CS, Cho JH. Spinal epidural involvement in adult Langerhans cell histiocytosis (LCH): A case report. Medicine (Baltimore). 2020 Jan;99(3):e18794. doi: 10.1097/MD.0000000000018794. PubMed PMID: 32011480.
5)
Bailey M, Mccabe M, Pal P, Agushi E, Karabatsou K. Cervical epidural extra-osseous Ewing sarcoma mimicking an epidural abscess. Br J Neurosurg. 2016 Feb;30(1):113-4. doi: 10.3109/02688697.2015.1071337. Epub 2015 Sep 7. PubMed PMID: 26982951.