title: Spinal epidural abscess with a rapid course in young healthy infantry recruits with multiple skin lacerations.
abstract: In recent years, there has been high prevalence of Staphylococcus aureus (S. aureus) infection among soldiers in the Israeli military, with devastating sequelae in several cases. Emergency department physicians have developed a high level of suspicion for spinal epidural abscess (SEA) in patients presenting known risk factors; however, SEA is a particularly elusive diagnosis in young healthy adults with no history of drug abuse. We review three cases of SEA secondary to methicillin-sensitive S. aureus (MSSA) infection in young healthy soldiers without known risk factors. We retrospectively reviewed clinical files of soldiers treated at our Medical Center from 2004-2015 to identify patients diagnosed with SEA. Those aged less than 30years with no history of intravenous drug use, spine surgery or spine trauma were included in the study. Three young army recruits met the inclusion criteria. These young men developed SEA through extension of MSSA infection to proximal skin and soft tissue from impetigo secondary to skin scratches sustained during "basic" training. All presented with mild nuchal rigidity and severe persistent unremitting lancinating radicular pain. Although healthy at baseline, they had a severe, rapidly progressive course. Following urgent surgery, two patients recovered after rehabilitation; one remained with paraparesis at late follow-up. Neurological deficits and systemic evidence of S. aureus infection progressed rapidly in these young healthy SEA patients with no history of drug abuse, emphasizing the critical role of timely MRI, diagnosis, and surgery.
authors.affiliation: Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; Israel Defense Forces Medical Corps, Tel Aviv, Israel.
authors.forename: Asaf
authors.initials: A
authors.lastname: Honig
authors.affiliation: Department of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Omer
authors.initials: O
authors.lastname: Or
authors.affiliation: Department of Orthopedic Surgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Yair
authors.initials: Y
authors.lastname: Barzilay
authors.affiliation: Department of Radiology, Hadassah-Hebrew University Medical Center, Department of Neurosurgery, POB 12000, Jerusalem 91120, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Shifra
authors.initials: S
authors.lastname: Fraifeld
authors.affiliation: Tzameret Military Medical Track, Hebrew University-Hadassah School of Medicine, Jerusalem, Israel.
authors.forename: Yoav Y
authors.initials: YY
authors.lastname: Pikkel
authors.affiliation: Department of Radiology, Hadassah-Hebrew University Medical Center, Department of Neurosurgery, POB 12000, Jerusalem 91120, Israel.
authors.forename: Ruth
authors.initials: R
authors.lastname: Eliahou
authors.affiliation: Department of Radiology, Hadassah-Hebrew University Medical Center, Department of Neurosurgery, POB 12000, Jerusalem 91120, Israel; Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: José E
authors.initials: JE
authors.lastname: Cohen
authors.affiliation: Department of Radiology, Hadassah-Hebrew University Medical Center, Department of Neurosurgery, POB 12000, Jerusalem 91120, Israel. Electronic address: eyal.itshayek@gmail.com.
authors.forename: Eyal
authors.initials: E
authors.lastname: Itshayek
mesh_terms: D000328:Adult; D020802:Epidural Abscess / Q000209:etiology* / Q000503:physiopathology* / Q000601:surgery; D006801:Humans; D007169:Impetigo / Q000150:complications*; D022125:Lacerations / Q000150:complications; D008279:Magnetic Resonance Imaging; D008297:Male; D008889:Military Personnel; D012189:Retrospective Studies; D012307:Risk Factors; D013211:Staphylococcus aureus
keywords: Impetigo; Radicular pain; Skin lacerations; Spinal epidural abscess; Staphylococcus aureus infection; Young infantry recruit