Epidural abscess differential diagnosis
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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]
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. [1] It may occur in two different places: 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.
Differential Diagnosis
Intracranial Epidural Abscess
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. [2] 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 adults, 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Tuberculous meningitis - consists in the inflammation of the meninges, caused by the organism Mycobacterium tuberculosis
- Cranial arteritis -
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. [3][4][5][6] Therefore, the differential diagnosis includes:
- Degenerative bone disease -
- Intervertebral disc disease -
- Bone tuberculosis -
- Primary or metastatic tumor -
- Vertebral osteomyelitis -
- Sciatica secondary to disc herniation -
- Meningitis -
- Herpes zoster - before appearance of skin lesions
References
- ↑ Longo, Dan L. (Dan Louis) (2012). Harrison's principles of internal medici. New York: McGraw-Hill. ISBN 978-0-07-174889-6.
- ↑ 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.
- ↑ Grewal, S. (2006). "Epidural abscesses". British Journal of Anaesthesia. 96 (3): 292–302. doi:10.1093/bja/ael006. ISSN 0007-0912.
- ↑ 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.
- ↑ 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.
- ↑ Keon-Cohen BT (1968). "Epidural abscess simulating disc hernia". J Bone Joint Surg Br. 50 (1): 128–30. PMID 5641580.