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NEUROLOGY 2008;71:e5
© 2008 American Academy of Neurology
Resident and Fellow Section

Teaching NeuroImage: Nocardial intramedullary spinal cord abscess

Lawrence M. Samkoff, MD, Ahmad Monajati, MD and Joel L. Shapiro, MD

From the Department of Neurology (L.M.S.), University of Rochester School of Medicine and Dentistry, and Departments of Radiology (A.M.) and Pathology (J.L.S.), Rochester General Hospital, Rochester, NY.

Address correspondence and reprint requests to Dr. Lawrence Samkoff, Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY14621

A 79-year-old man with ulcerative colitis on chronic prednisone therapy developed severe midcervical pain and progressive weakness of the left arm and leg over several days. This was associated with left forearm paresthesias and urinary hesitancy and incontinence. He had no cranial or bulbar symptoms. On general examination, he was afebrile but there was midcervical spine tenderness. Neurologic examination revealed normal mental status and cranial nerves; strength was 2/5 on the left, and 4/5 on the right; there was a sensory level to pain and temperature on the right to C4, with reduced proprioception in the left foot and hand; there was a left Babinski sign and a mute right plantar response. White blood cell count was 18.2 x 109/L. Blood cultures were negative. Chest CT demonstrated multiple lung nodules. Cervical spine MRI (figure 1) revealed an intramedullary ring-enhancing mass on the left at C3-4 associated with edema from C2 to C7. Open spinal cord biopsy revealed Nocardia farcinica abscess (figure 2). Lumbar puncture and bronchoscopy were not performed. The patient was treated with IV trimethoprim-sulfamethoxazole and dexamethasone. After 10 days, lower extremity strength improved bilaterally. Left arm strength and sensory deficits remained unchanged. He died 8 weeks later due to cardiac arrest. No autopsy was performed.


Figure 116
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  		Figure 1 Gadolinium-enhanced axial (A) and sagittal (B) T1 fat-saturated MRI of the cervical spine demonstrating intramedullary abscess at the left C3-4 level, associated with enlargement of the spinal cord from C2 to C7

 

Figure 216
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  		Figure 2 Branching, filamentous, beaded bacteria identified within necrotic debris

The microorganisms were stained by GMS (silver) and Fite (modified acid fast) stains; they did not stain on Ziehl-Neelsen (conventional acid fast) or tissue gram stains. The morphologic and staining characteristics are most consistent with Nocardia species. Fite stain at 100x (oil) is shown.

 

CNS nocardiosis is usually associated with systemic nocardial infection. Although brain abscess is the most common presentation of CNS nocardiosis, rare cases of intramedullary spinal cord abscess have been reported.1,2 Nocardia abscess should be considered in immunocompromised patients with spinal cord syndromes. Expeditious tissue diagnosis and antibiotic therapy are essential to improved outcomes.

lawrence.samkoff{at}viahealth.org

Disclosure: The authors report no disclosures.


   REFERENCES
Top.
 REFERENCES
 

  1. Mukunda BN, Shekar R, Bass S. Solitary spinal intramedullary abscess caused by Nocardia asteroides. South Med J 1999;92:1223–1224.[Medline]
  2. Durmaz R, Metin AA, Durmaz G, et al. Multiple nocardial abscess of cerebrum, cerebellum, and spinal cord, causing quadriplegia. Clin Neuro Neurosurg 2001;103:59–62.



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