1412. Spontaneous Intramedullary Abscess from Streptococcus anginosus Group: A Case Report and a Review of the Literature

BACKGROUND: Intramedullary abscess of the spinal cord (IASC) symptoms are often nonspecific with the diagnosis rarely considered on the initial differential. This can delay surgical management and may lead to permanent neurological deficits or mortality. Additionally, many organisms are implicated in IASC, leading to uncertainty in empiric antimicrobial therapy. METHODS: This case report follows a patient with IASC due to Streptococcus anginosus group (SAG). We also review a 25-case meta-analysis of IASC and 5 cases of SAG IASC. RESULTS: A 65-year-old woman with an unremarkable past medical history presented with 2 weeks of neck pain and paresthesias. She was afebrile with no systemic signs of infection or abnormal laboratory markers. MRI revealed an 8mm lesion at C4-C5 with edema C1-T1 and she received high-dose steroids for suspected malignancy. Follow-up MRI 4 days later revealed rapid progression of the lesion to 14mm, consistent with an infectious process (Figure 1). The patient received empiric therapy with ceftriaxone, vancomycin, and metronidazole. She underwent a C2-C7 laminectomy with midline myelotomy for evacuation of the abscess. Due to clinical and radiographic progression she required a second surgical wash-out 4 days later. Her intraoperative cultures grew SAG and her regimen was changed to penicillin and vancomycin. Her course was complicated by eosinophilia requiring meropenem and later linezolid to complete a 6-week course, during which she improved clinically and neurologically. Our review demonstrated that 40% of cases presented with fever. The majority of cases were idiopathic with the organisms known in 70% of cases. Surgery and IV antibiotics were used in 83% of cases and one case required a second surgery. A wide range of antibiotic regimens were reported with no consensus on how to best preserve neurological function. CONCLUSION: This case highlights the complexities in diagnosing and managing IASC. We suspect that due to the protected nature of the intramedullary space, the infection may not trigger constitutional symptoms or a systemic inflammatory response. In patients who present with significant neurological deficits, MRI may reveal IASC and this should prompt immediate initiation of antibiotics that penetrate the blood–brain barrier and surgical intervention. [Image: see text] [Image: see text] DISCLOSURES: All authors: No reported disclosures.