A 66yo diabetic  female with a history of a recent febrile illness now presents with increasing weakness and altered sensation  in both legs. A lumbar puncture is performed and the initial CSF result is shown.

Red blood cells
Polymorphs

594 x 106/L
550 x 106/L

(0-5 x 106/L) (0-5 x 106/L)

Mononuclear cells

154 x 106/L

Protein

0.99g/L

(0.15 – 0.40g/L)

Glucose

10.4 mmol/L

(2.5-5.6 mmol/L)

No organisms seen

a). What is the most important diagnostic  investigation indicated in this clinical scenario?

b). What is the most likely diagnosis?

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College Answer

a). What is the most important diagnostic  investigation indicated in this clinical scenario?
MRI of the spine

b). What is the most likely diagnosis?
Epidural abscess

Discussion

This elderly diabetic woman has a bilateral motor and sensory loss in her legs. The CSF looks infected; perhaps the glucose is raised, but this could be because the serum glucose is also raised, so I would not be deterred from a suspicion of epidural abscess by the presence of these findings.

The most important investigation in this context would be an MRI of the whole spine.

References

Reihsaus, E., H. Waldbaur, and W. Seeling. "Spinal epidural abscess: a meta-analysis of 915 patients." Neurosurgical review 23.4 (2000): 175-204.