Spinal epidural abscess associated with an epidural catheter in a woman with complex regional pain syndrome and selective IgG3 deficiency: A case report

Abstract

Rationale: Continuous epidural infusion of local anesthetic may be an alternative to sympathetic blocks in refractory cases of complex regional pain syndrome (CRPS). Spinal epidural abscess (SEA) is a well-known complication associated with this technique, especially in patients with immune deficiencies. We herewith report a cervical SEA associated with an epidural catheter in a woman with CRPS and selective IgG3 subclass deficiency.

Patient concerns: Severe pain interfering with activities of daily living.

Diagnosis: Complex regional pain syndrome type-1 with involvement of upper extremity.

Interventions: The patient underwent inpatient epidural infusion for management of left upper extremity CRPS. Her history was notable for previous left shoulder injury requiring numerous surgical revisions complicated by recurrent shoulder infections, and selective IgG3 deficiency. She received antibiotic prophylaxis and underwent placement of a C6-C7 epidural catheter. On day 5, she became febrile. Neurological examination remained unchanged and an MRI demonstrated acute fluid collection from C3-T1. The following day she developed left arm weakness and was taken for emergent cervical decompression. Intraoperative abscess cultures were positive for Pseudomonas aeruginosa.

Outcomes: Postoperatively, the patient's neurological symptoms and signs improved.

Lessons: Patients with selective IgG3 deficiency who are being considered for epidural catheterization may benefit from expert consultation with infectious diseases specialist. A history of recurrent device- or tissue-related infections should alert the clinician to the possible presence of a biofilm or dormant bacterial colonization. Close monitoring in an ICU setting during therapy is recommended. In case of early signs of infection, clinicians should have a high suspicion to rule out a SEA in immunocompromised patients.

Figures

Figure 1

Procedural fluoroscopy. (A) AP and (B) lateral views of epidural catheter placed in the left C6–C7 interlaminar space with distal tip in the C4–C5 interspace.

Figure 2

Cervical spine MRI with IV contrast. (A) Axial 2D multiple echo recombined gradient echo (MERGE) view and (B) sagittal inversion recovery (IR) view showing a fluid collection in the cervical epidural space, coursing from C3 to T1 (white arrows). MRI = magnetic resonance imaging, MERGE = multiple echo recombined gradient echo.