A 34-year-old woman came to the emergency room complaining of a severe orthostatic headache. Results of a cerebrospinal fluid tap and brain computed tomography were normal. Based on her history and symptoms, she was found to have spontaneous intracranial hypotension. She was hospitalized and her symptoms improved with conservative treatment. On the next day, her headache suddenly worsened. Cisternography was performed to confirm the diagnosis and determine the spinal level of her cerebrospinal fluid leak. It revealed multiple cerebrospinal fluid leaks in the lumbar and upper thoracic regions. It was strongly believed that she had an iatrogenic cerebrospinal fluid leak in the lumbar region. An epidural blood patch was performed level by level on the lumbar and upper thoracic regions. Her symptoms resolved after the epidural blood patch and she was later discharged without any complications. In this case, an iatrogenic cerebrospinal fluid leak was caused by a dural puncture made while diagnosing spontaneous intracranial hypotension, which is always a risk and hampers the patient's progress. Therefore, in cases of spontaneous intracranial hypotension, an effort to minimize dural punctures is needed and a non-invasive test such as magnetic resonance imaging should be considered first.

Citations

Citations to this article as recorded by  

• Intracranial Hypotension and Cerebrospinal Fluid Leak
  Stephen M. Chan, Yosef G. Chodakiewitz, Marcel M. Maya, Wouter I. Schievink, Franklin G. Moser
  Neuroimaging Clinics of North America.2019; 29(2): 213.     CrossRef

Diagnoses of pyelonephritis caused by Staphylococcus aureus should be accompanied by investigations of concomitant bladder obstruction and metastatic infections, especially to the spine or heart. Complicated pyelonephritis due to S. aureus requires more than 2 weeks of antibiotics, which is the typically recommended treatment duration for pyelonephritis. We describe a patient who was diagnosed with complicated epidural and paraspinal abscesses after insufficient evaluation and treatment of acute pyelonephritis due to S. aureus. A 62-year-old man with type 2 diabetes was admitted with fever, increased urinary frequency, and left flank pain. He was diagnosed with acute pyelonephritis caused by S. aureus. His fever and flank pain subsided after 3 days of intravenous antibiotics. Evaluation of bladder obstruction and metastatic infection were not performed, as he declined further evaluation. The patient was discharged with oral antibiotics and was requested to attend weekly appointments but was lost to follow-up. One month later, the patient presented at the outpatient clinic with similar symptoms. Computed tomography showed recurrent pyelonephritis and a distended bladder. His flank pain persisted despite administration of an opioid agent. Therefore, magnetic resonance imaging was performed, revealing epidural and paraspinal abscesses. Ultrasound-guided aspiration of the paraspinal muscle layer was performed, and blood and percutaneous aspirated fluid cultures revealed S. aureus growth. The pattern of antimicrobial sensitivity was identical to that at his first admission. Following more than 4 weeks of antibiotics, magnetic resonance imaging showed the abscesses had decreased in size. The patient was discharged without neurologic sequelae and was provided with oral antibiotics.

Citations

Citations to this article as recorded by  

• A Case Presenting with a Paraspinal Muscle Abscess Complicated by Suspected Iodoform Poisoning During Treatment
  Shunya Tamamine, Atsuyuki Kuro, Masayuki Nakano, Shuhei Matsunami, Hiroaki Sakurai, Sakurako Kunieda, Kenji Suzuki, Natsuko Kakudo
  International Journal of Surgical Wound Care.2025; 6(2): 64.     CrossRef
• Spinal epidural abscess due to acute pyelonephritis
  Gianluca Scalia, Salvatore Marrone, Federica Paolini, Paolo Palmisciano, Giancarlo Ponzo, Massimiliano Giuffrida, Massimo Furnari, Domenico Gerardo Iacopino, Giovanni Federico Nicoletti, Giuseppe Emmanuele Umana
  Surgical Neurology International.2022; 13: 159.     CrossRef
• Primary Spinal Epidural Abscesses Not Associated With Pyogenic Infectious Spondylodiscitis: A New Pathogenetic Hypothesis
  Lorenzo Magrassi, Marco Mussa, Andrea Montalbetti, Marta Colaneri, Angela di Matteo, Antonello Malfitano, Anna Maria Simoncelli, Maria Grazia Egitto, Claudio Bernucci, Enrico Brunetti
  Frontiers in Surgery.2020;[Epub]     CrossRef