Cardiovascular Medicine and Surgery NetWork Puzzler - March 2010

MSSA endocarditis, epidural abscess

Hospital course

Neurology concluded that the weakness in the patient’s feet was caused by epidural abscess compressing the spinal cord. He underwent emergent L3, L4, and L5 laminectomy and decompression of the epidural abscess. Purulent drainage was obtained and a culture of the drainage specimen grew MSSA. The thecal sac was intact and was irrigated with antibiotics solution. After laminectomy, the patient’s leg weakness was improved; however, he remained febrile and his blood culture persistently grew MSSA. Five days after laminectomy, he was taken to the OR for mitral valve surgery. Inspecting the mitral valve, there was a large vegitation on the posterior leaflet of the mitral valve, which was perforated in multiple areas. Gram stain of the vegetation was positive for gram-positive cocci, which was later found to be MSSA. The mitral valve was replaced with a tissue valve. His postoperative course was uneventful, and he was discharged to home on postoperative day 8 with 6 weeks of antibiotics treatment.

Discussion

Stabilization of the septic shock is the initial treatment of endocarditis. Investigation of the primary source of sepsis is important. Echocardiography is the most valuable diagnostic modality to diagnose endocarditis. Medical treatment with antibiotics is the first-line treatment for endocarditis. The infectious source should be controlled before cardiac surgery for endocarditis. The most important indications for surgery of endocarditis are uncontrolled heart failure due to valvular destruction (class I recommendation), perivalvular abscess or fistula formation (class I recommendation), persistent septicemia despite appropriate antibiotics treatment (class IIa recommendation), and recurrent embolic episodes (class IIa recommendation). Mobile and/or large size vegetation is another indication for surgery; however, it is a class IIb recommendation.¹

The presented case demonstrated a rare combination of epidural abscess and endocarditis. A patient with bilateral weakness of the feet, back pain, and fever should be investigated with MRI or CT scan to rule out epidural abscess.² Since spontaneous epidural abscess is rare, investigation of the primary source of infection such as endocarditis is necessary.

References

1. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52(13):e1-e142.
2. Cone LA, Hirschberg J, Lopez C, et al. Infective endocarditis associated with spondylodiscitis and frequent secondary epidural abcess. Surg Neurol. 2008;69(2):121-125.