Central Nervous System Infections

Case 3:

Mr. Tom Riddle is admitted to your hospital for persistent back pain that has been occurring for the past week. He has no other symptoms and is not inclined to provide you with much of a history. After much deliberation, he confesses to you that he has been injecting himself with unicorn blood. What is the next best step?

a.       Obtain two sets of blood cultures.

b.       Obtain an MRI of the spine.

c.       Start empiric vancomycin IV (goal trough 15-20).

d.       Obtain a transthoracic echocardiogram (TTE).

e.       Consult Spine Surgery.

Explanation:

Given Mr. Riddle’s history of injection unicorn (drug?) use, you should be concerned about bacteremia with subsequent seeding to the spine and development of a spinal epidural abscess. The correct answer is A. Other risk factors for spinal epidural abscess include prolonged epidural catheter placement, paraspinal steroid injections, diabetes, HIV infection, trauma, tattooing, alcoholism and acupuncture. (The latter has been described in case reports, typically in the cervical area.)

Get two sets of blood cultures first; the causative agent can be confirmed from these initial blood cultures >60% of the time! Then order an MRI of the spine with contrast (CT of the spine with contrast is also acceptable). If possible, obtain image-guided aspiration and send for cultures prior to starting empiric antibiotic therapy.