Two cases of spontaneous epidural abscess in patients with cirrhosis.

To the Editor: We read with interest the recent case report by Cross and Howell (1) regarding the association of cirrhosis and spinal epidural abscess (SEA). In the introduction, the authors stated, "To our knowledge, chronic liver disease has not previously been identified as a condition predisposing to epidural abscesses" (p 291). In the conclusion, they stated, "To our knowledge, this article describes the first series in which a link was found between epidural abscess and cirrhosis" (p 293). Although cirrhosis is not commonly identified in association with the development of SEA, there have been several other reports documenting SEA in patients with liver cirrhosis.

Hung et al (2) described an elderly patient with a 10-year history of liver cirrhosis who developed Haemophilus aphrophilus baeteremia with subsequent development of vertebral osteomyelitis and SEA in the lumbar spine, both of which were diagnosed on the basis of magnetic resonance imaging findings. This patient was treated conservatively and successfully with cefotaxime and ciprofioxacin. These authors did not emphasize the association of SEA with liver cirrhosis, and the patient's history was significant for a fall from three steps 1 week before hospital admission. Blunt trauma to the spine is a risk factor for SEA, and the temporal proximity of the patient's fall to the onset of her illness may have been a more significant factor than liver cirrhosis.

Wagner et al (3) reported a case of SEA in a male patient with alcoholic cirrhosis who died after developing an epidural abscess in the thoracic spine. The diagnosis of SEA as a result of contiguous spread of Aspergillus fumigatus lung infection was delayed by 3 weeks despite abnormal cerebrospinal fluid findings derived from multiple spinal taps. Delay in the diagnosis and correct treatment may result in neurologic deficits and death. It was the development of paraplegia in this patient that prompted computed tomography of the thorax and directed the differential diagnosis toward SEA. The patient had been treated with corticosteroids for approximately 6 months, which may have led to some degree of immune system compromise. These authors did suggest that liver cirrhosis, in addition to chronic alcoholism and prolonged steroid treatment, may have predisposed the patient to extension of the patient's right upper lobe aspergillus infection, leading to SEA.

These two cases reinforce the contention by Cross and Howell (1) that clinicians should contemplate SEA as a source of infection in patients with liver cirrhosis, especially when patients complain of back pain or have either abnormal cerebrospinal fluid or imaging findings. Early consideration of this uncommon condition can help avoid the potential irreversible neurologic damage and death that can occur if diagnosis and treatment are delayed.

James Bradley Summers, MS, MD

Department of Diagnostic Radiology

University of South Alabama 

Mobile, AL

Joseph Kaminski, MD

Department of Radiology

Medical College of Georgia 

Augusta, GA

References

(1.) Cross RK Jr, Howell C. Two cases of spontaneous epidural abscess in patients with cirrhosis. South Med J 2003;96:291-293.

(2.) Hung CC, Hsueh PR, Chen YC, et al. Haemophilus aphrophilus bacteraemia complicated with vertebral osteomyelitis and spinal epidural abscess in a patient with liver cirrhosis. J Infect 1997;35:304-308.

(3.) Wagner DK, Varkey B, Shetb NK, et al. Epidural abscess, vertebral destruction, and paraplegia caused by extending infection from an aspergiiloma. Am J Med 1985;78:518-522.