Epidural abscess differential diagnosis: Difference between revisions

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{{Epidural abscess}}
{{Epidural abscess}}
{{CMG}}; {{AE}} {{JS}}
{{CMG}} {{AE}} {{JS}}; {{AG}}


==Overview==
==Overview==
An epidural abscess is a rare suppurative infection of the [[central nervous system]], a collection of [[pus]] localised in the [[epidural space]] lying outside the [[dura mater]], which accounts for less than 2% of focal [[CNS]] infections. <ref>{{Cite book  | last1 = Longo | first1 = Dan L. (Dan Louis) | title = Harrison's principles of internal medici | date = 2012 | publisher = McGraw-Hill | location = New York | isbn = 978-0-07-174889-6 | pages =  }}</ref> It may occur in two different places: [[intracranial space|intracranially]] or in the [[spinal canal]]. The diagnosis of epidural abscess, due to the unspecific clinical symptoms, is rarely  a quick diagnosis. It is suspected based on clinical findings, along with laboratory data and imaging tests, however it can only be confirmed by surgical drainage. According to the location of the abscess, different conditions must be considered in the differential diagnosis.
Intracranial epidural abscess must be differentiated from [[epidural hematoma]], [[subdural empyema]], [[brain abscess]], [[tuberculous meningitis]], and other intracranial mass lesions. Spinal epidural abscess must be differentiated from other conditions that cause [[back pain]], [[weakness]], and spinal [[tenderness]], such as [[arthritis]], [[osteoarthritis]], [[intervertebral disc]] disease, [[vertebral osteomyelitis]], [[primary tumor|primary]] or [[metastatic tumor]]s, and [[musculoskeletal pain]].


==Differential Diagnosis==
==Differential Diagnosis==
===Intracranial Epidural Abscess===
Intracranial epidural abscess must be differentiated from other diseases that cause [[headache]], [[vomiting]], [[fever]], [[altered mental status]], [[seizures]], [[cranial nerve]] abnormalities, and [[paresis]].<ref name="pmid15043336">{{cite journal| author=Fountas KN, Duwayri Y, Kapsalaki E, Dimopoulos VG, Johnston KW, Peppard SB et al.| title=Epidural intracranial abscess as a complication of frontal sinusitis: case report and review of the literature. | journal=South Med J | year= 2004 | volume= 97 | issue= 3 | pages= 279-82; quiz 283 | pmid=15043336 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15043336  }} </ref> Intracranial epidural abscess must be differentiated from:


===Intracranial Epidural Abscess===
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
An intracranial epidural abscess can replicate the [[signs]] and [[symptoms]] of any intracranial mass lesion. It may be presented by [[headache]],  [[vomiting]],  [[fever]],  [[altered mental status]],  [[seizures]],  [[cranial nerve]] abnormalities  and [[paresis]].  However, these signs may not be present initially, and may be shared by other conditions, which increases the complexity of the differential diagnosis. <ref name="pmid15043336">{{cite journal| author=Fountas KN, Duwayri Y, Kapsalaki E, Dimopoulos VG, Johnston KW, Peppard SB et al.| title=Epidural intracranial abscess as a complication of frontal sinusitis: case report and review of the literature. | journal=South Med J | year= 2004 | volume= 97 | issue= 3 | pages= 279-82; quiz 283 | pmid=15043336 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15043336  }} </ref> Therefore, the differential diagnosis includes:
|+
*'''Primary parenchymal [[tumor]]''' - consists in any [[intracranial tumor]] located, and with its origin, at the [[brain]] parenchyma. Although they can be located anywhere in the [[brain]] parenchyma, in [[children]] they are commonly located in the [[posterior cranial fossa]],  while in [[adult]]s, they can affect any part of the [[brain]]. Because of the diversity of locations [[brain]] parenchymal [[tumors]] may take, there may also be many different [[signs]] and [[symptoms]]. These include: [[focal neurologic signs]], increasing [[intracranial pressure]] and [[seizures]].
! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Disease}}
*'''[[Metastatic tumor]]''' - consists in any [[intracranial tumor]], which has spread from another organ or [[tissue]], making the [[brain tumor]], a secondary [[tumor]]. Depending on the location of the [[brain]] affected, there will be different [[signs]] and [[symptoms]]. These may include: [[focal neurologic signs]], increasing [[intracranial pressure]], [[seizures]] and others, which may mimic sins and symptoms from epidural abscess.
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Findings}}
*'''[[Meningioma]]''' - consists in a [[tumor]] arising from the arachnoidal cap cells of the [[meninges]]. In 95% of the cases it's a [[benign tumor]]. Depending on the size and location of the [[tumor]],  different areas of the [[brain]] may be affected, therefore it may manifest itself with different [[signs]] and [[symptoms]], including [[focal neurologic signs]], increasing [[intracranial pressure]] and [[seizures]]. Since these are shared with epidural abscess, this condition should be in the differential diagnosis.
|-
*'''[[Hematoma]]''' - consists in a collection of [[blood]], usually resulting from an [[haemorrhage]]. I may appear as a [[bruise]], if it occurs near the skin, or in [[internal organs]]. In the case of happening in the [[brain]], it may work as a [[mass effect]], compressing various structures of the [[brain]], hence causing different [[signs]] and [[symptoms]]. These may me similar to those of epidural abscess and therefore should be part of the differential diagnosis.
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Hematoma]]'''
*'''[[Subdural empyema]]''' - consists of a collection of [[purulent]] material, accumulating in the [[subdural space]]. Once it exerts a [[mass effect]], it may compress other [[brain]] structures, causing various [[signs]] and [[symptoms]]. Since it also represents an [[inflammatory]] component, the [[inflammation]] might spread to other [[brain]] structures, affecting their normal functioning. The [[signs]] and [[symptoms]] may include: [[fever]], [[headache]], [[altered mental status]] and [[seizures]]. As these [[symptoms]] are shared by epidural abscess, it should be part of the differential diagnosis.
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with a collection of [[blood]] or [[bruise]] (if it occurs near the [[skin]]). If it occurs near the [[brain]], it may act as a [[mass effect]], and the patient may present with [[increased intracranial pressure]], midline shift, and [[brain herniation]].
*'''[[Brain abscess]]''' - consists of a collection of [[purulent]] material within the [[brain]] tissue. The [[infection]] may originate in a local tissue, such as [[paranasal sinuses]], remote tissue, such as [[lung]] or [[kidney]], or be introduced during [[neurosurgery]] or head [[trauma]]  Either the [[infection]] of the [[brain]] tissue, or the [[mass effect]] caused by it, may cause [[signs]] and [[symptoms]], similar to the ones of epidural abscess.
|-
*'''[[Meningitis|Chronic meningitis]]''' - consists in the [[inflammation]] of the [[meninges]], as a response to [[infectious agents]], certain [[drugs]], [[trauma]] or [[cancer]]. The [[inflammatory]] process will cause [[signs]] and [[symptoms]] such as [[headache]], [[nuchal rigidity]], [[fever]] and [[altered mental status]], which are similar to those of epidural abscess.
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Epidural hematoma]]'''
*'''[[Tuberculous meningitis]]''' - consists in the [[inflammation]] of the [[meninges]], caused by the organism ''[[Mycobacterium tuberculosis]]''. [[Fever]] and [[headache]] are the cardinal symptoms, however, other [[symptoms]] such as [[confusion]] and [[focal neurologic signs]] may also be present.
| style="padding: 5px 5px; background: #F5F5F5;" |Presents with a collection of [[blood]] in the [[epidural space]], [[headache]], [[back pain]], [[confusion]], [[weakness]],  and [[focal neurologic signs]]
*'''[[Cranial arteritis]]''' -
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Subdural empyema]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |Presents with a collection of [[purulent]] material accumulating in the [[subdural space]], [[mass effect]], [[fever]], [[headache]], [[altered mental status]], and [[seizures]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Brain abscess]] '''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with a collection of [[purulent]] material within the [[brain]] tissue, [[confusion]], decreased movement, decreased sensation, decreasing responsiveness, [[drowsiness]], [[fever]], [[headache]], [[loss of coordination]], [[nausea]], [[seizure]], and [[vomiting]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Meningitis|Chronic meningitis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[inflammation]] of the [[meninges]], [[headache]], [[nuchal rigidity]], [[fever]], and [[altered mental status]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Tuberculous meningitis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[inflammation]] of the [[meninges]], [[fever]], [[headache]], [[confusion]], and [[focal neurologic signs]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Tumor]], including primary parenchymal, [[metastatic]], and [[meningioma]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with an [[intracranial tumor]], [[focal neurologic signs]], [[increased intracranial pressure]], and [[seizures]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Temporal arteritis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[inflammation]] of the [[blood vessels]] of the [[head]], commonly the large and medium [[arteries]], [[fever]], [[headache]], and [[focal neurologic signs]]
|-
|}


===Spinal Epidural Abscess===
===Spinal Epidural Abscess===
At the time of presentation, the diagnosis of spinal epidural abscess is only suspected in 40% of the cases. This is due to the fact that there are several other conditions, more common than this type of abscess, presenting with similar signs and symptoms. Spinal epidural abscess usually presents with [[back pain]], [[fever]], motor [[weakness]], and spinal [[tenderness]]. <ref name="Grewal2006">{{cite journal|last1=Grewal|first1=S.|title=Epidural abscesses|journal=British Journal of Anaesthesia|volume=96|issue=3|year=2006|pages=292–302|issn=0007-0912|doi=10.1093/bja/ael006}}</ref><ref name="pmid8333809">{{cite journal| author=Maslen DR, Jones SR, Crislip MA, Bracis R, Dworkin RJ, Flemming JE| title=Spinal epidural abscess. Optimizing patient care. | journal=Arch Intern Med | year= 1993 | volume= 153 | issue= 14 | pages= 1713-21 | pmid=8333809 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8333809  }} </ref><ref name="pmid1467114">{{cite journal| author=Ngan Kee WD, Jones MR, Thomas P, Worth RJ| title=Extradural abscess complicating extradural anaesthesia for caesarean section. | journal=Br J Anaesth | year= 1992 | volume= 69 | issue= 6 | pages= 647-52 | pmid=1467114 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1467114  }} </ref><ref name="pmid5641580">{{cite journal| author=Keon-Cohen BT| title=Epidural abscess simulating disc hernia. | journal=J Bone Joint Surg Br | year= 1968 | volume= 50 | issue= 1 | pages= 128-30 | pmid=5641580 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5641580  }} </ref> Therefore, the differential diagnosis includes:
Spinal epidural abscess must be differentiated from other diseases that cause [[back pain]], [[fever]], [[weakness]], and spinal [[tenderness]].<ref name="Grewal2006">{{cite journal|last1=Grewal|first1=S.|title=Epidural abscesses|journal=British Journal of Anaesthesia|volume=96|issue=3|year=2006|pages=292–302|issn=0007-0912|doi=10.1093/bja/ael006}}</ref><ref name="pmid8333809">{{cite journal| author=Maslen DR, Jones SR, Crislip MA, Bracis R, Dworkin RJ, Flemming JE| title=Spinal epidural abscess. Optimizing patient care. | journal=Arch Intern Med | year= 1993 | volume= 153 | issue= 14 | pages= 1713-21 | pmid=8333809 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8333809  }} </ref><ref name="pmid1467114">{{cite journal| author=Ngan Kee WD, Jones MR, Thomas P, Worth RJ| title=Extradural abscess complicating extradural anaesthesia for caesarean section. | journal=Br J Anaesth | year= 1992 | volume= 69 | issue= 6 | pages= 647-52 | pmid=1467114 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1467114  }} </ref><ref name="pmid5641580">{{cite journal| author=Keon-Cohen BT| title=Epidural abscess simulating disc hernia. | journal=J Bone Joint Surg Br | year= 1968 | volume= 50 | issue= 1 | pages= 128-30 | pmid=5641580 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5641580  }} </ref> Therefore, spinal epidural abscess must be differentiated from:
*'''[[Degenerative]] bone disease''' -  
 
*'''[[Intervertebral disc]] disease''' -  
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
*'''Bone [[tuberculosis]]''' -  
|+
*'''Primary or [[metastatic]] [[tumor]]''' -  
! style="background: #4479BA; width: 120px;" | {{fontcolor|#FFF|Disease}}
*'''[[Vertebral osteomyelitis]]''' -  
! style="background: #4479BA; width: 550px;" | {{fontcolor|#FFF|Findings}}
*'''[[Spinal disc herniation|Sciatica secondary to disc herniation]]''' -  
|-
*'''[[Meningitis]]''' -  
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Musculoskeletal pain]]'''
*'''[[Herpes zoster]]''' - before appearance of skin lesions
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[lower back pain]] following overuse and over stretching of [[muscles]], or in the context of a [[viral infection]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Arthritis]] and [[Osteoarthritis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[back pain]], [[stiffness]], [[tenderness]], and [[weakness]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Degenerative disc disease]] '''
| style="padding: 5px 5px; background: #F5F5F5;" |Presents with [[lower back pain]], [[tenderness]], and [[weakness]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Spinal disc herniation]] '''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with the soft central [[nucleus pulposus]] bulging out, [[lower back pain]], [[leg pain]], [[tingling]], [[numbness]], and  [[reflex]] changes
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Shingles]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with painful [[skin rash]], [[blisters]], [[fever]], [[headache]], [[chills]], and [[tingling]] sensations
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Spinal cord]] [[ischemia]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[radiculopathy]], [[weakness]] and [[pain]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Vertebral osteomyelitis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with infected [[bone]] and [[bone marrow]], [[fever]], [[back pain]], [[swelling]], [[weakness]] of the [[vertebral column]] and surrounding [[muscles]], and [[night sweats]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Leukemia]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[bruises]], [[dyspnea]], [[fever]], [[chills]], [[weakness]], [[fatigue]], [[headache]], and [[bone pain|bone]] and [[joint pain]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''[[Epidural hematoma]]'''
| style="padding: 5px 5px; background: #F5F5F5;" |Presents with a collection of [[blood]] in the [[epidural space]], [[headache]], [[back pain]], [[confusion]], [[weakness]],  and [[focal neurologic signs]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Meningitis|Chronic meningitis]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[inflammation]] of the [[meninges]], [[headache]], [[nuchal rigidity]], [[fever]], and [[altered mental status]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[Tumor]]'''
| style="padding: 5px 5px; background: #F5F5F5;" | Presents with [[focal neurologic signs]], [[increased intracranial pressure]], [[lower back pain]], and [[seizures]]
|-
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Wikinfect]]
[[Category:Infectious disease]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Primary care]]

Latest revision as of 21:36, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]; Anthony Gallo, B.S. [3]

Overview

Intracranial epidural abscess must be differentiated from epidural hematoma, subdural empyema, brain abscess, tuberculous meningitis, and other intracranial mass lesions. Spinal epidural abscess must be differentiated from other conditions that cause back pain, weakness, and spinal tenderness, such as arthritis, osteoarthritis, intervertebral disc disease, vertebral osteomyelitis, primary or metastatic tumors, and musculoskeletal pain.

Differential Diagnosis

Intracranial Epidural Abscess

Intracranial epidural abscess must be differentiated from other diseases that cause headache, vomiting, fever, altered mental status, seizures, cranial nerve abnormalities, and paresis.[1] Intracranial epidural abscess must be differentiated from:

Disease Findings
Hematoma Presents with a collection of blood or bruise (if it occurs near the skin). If it occurs near the brain, it may act as a mass effect, and the patient may present with increased intracranial pressure, midline shift, and brain herniation.
Epidural hematoma Presents with a collection of blood in the epidural space, headache, back pain, confusion, weakness, and focal neurologic signs
Subdural empyema Presents with a collection of purulent material accumulating in the subdural space, mass effect, fever, headache, altered mental status, and seizures
Brain abscess Presents with a collection of purulent material within the brain tissue, confusion, decreased movement, decreased sensation, decreasing responsiveness, drowsiness, fever, headache, loss of coordination, nausea, seizure, and vomiting
Chronic meningitis Presents with inflammation of the meninges, headache, nuchal rigidity, fever, and altered mental status
Tuberculous meningitis Presents with inflammation of the meninges, fever, headache, confusion, and focal neurologic signs
Tumor, including primary parenchymal, metastatic, and meningioma Presents with an intracranial tumor, focal neurologic signs, increased intracranial pressure, and seizures
Temporal arteritis Presents with inflammation of the blood vessels of the head, commonly the large and medium arteries, fever, headache, and focal neurologic signs

Spinal Epidural Abscess

Spinal epidural abscess must be differentiated from other diseases that cause back pain, fever, weakness, and spinal tenderness.[2][3][4][5] Therefore, spinal epidural abscess must be differentiated from:

Disease Findings
Musculoskeletal pain Presents with lower back pain following overuse and over stretching of muscles, or in the context of a viral infection
Arthritis and Osteoarthritis Presents with back pain, stiffness, tenderness, and weakness
Degenerative disc disease Presents with lower back pain, tenderness, and weakness
Spinal disc herniation Presents with the soft central nucleus pulposus bulging out, lower back pain, leg pain, tingling, numbness, and reflex changes
Shingles Presents with painful skin rash, blisters, fever, headache, chills, and tingling sensations
Spinal cord ischemia Presents with radiculopathy, weakness and pain
Vertebral osteomyelitis Presents with infected bone and bone marrow, fever, back pain, swelling, weakness of the vertebral column and surrounding muscles, and night sweats
Leukemia Presents with bruises, dyspnea, fever, chills, weakness, fatigue, headache, and bone and joint pain
Epidural hematoma Presents with a collection of blood in the epidural space, headache, back pain, confusion, weakness, and focal neurologic signs
Chronic meningitis Presents with inflammation of the meninges, headache, nuchal rigidity, fever, and altered mental status
Tumor Presents with focal neurologic signs, increased intracranial pressure, lower back pain, and seizures

References

  1. ↑ Fountas KN, Duwayri Y, Kapsalaki E, Dimopoulos VG, Johnston KW, Peppard SB; et al. (2004). "Epidural intracranial abscess as a complication of frontal sinusitis: case report and review of the literature". South Med J. 97 (3): 279–82, quiz 283. PMID 15043336.
  2. ↑ Grewal, S. (2006). "Epidural abscesses". British Journal of Anaesthesia. 96 (3): 292–302. doi:10.1093/bja/ael006. ISSN 0007-0912.
  3. ↑ Maslen DR, Jones SR, Crislip MA, Bracis R, Dworkin RJ, Flemming JE (1993). "Spinal epidural abscess. Optimizing patient care". Arch Intern Med. 153 (14): 1713–21. PMID 8333809.
  4. ↑ Ngan Kee WD, Jones MR, Thomas P, Worth RJ (1992). "Extradural abscess complicating extradural anaesthesia for caesarean section". Br J Anaesth. 69 (6): 647–52. PMID 1467114.
  5. ↑ Keon-Cohen BT (1968). "Epidural abscess simulating disc hernia". J Bone Joint Surg Br. 50 (1): 128–30. PMID 5641580.
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