Abstract

Background: In a 31-year-old male, psoriasis vulgaris (PV) of the skin caused paraparesis attributed to a L3-L4 epidural spinal abscess that required emergent surgical decompression.

Case Description: A 31-year-old male presented with lower back pain and cauda equina compression attributed to a magnetic resonance-documented L34 enhancing lesion consistent with a spinal epidural abscess (SEA). The skin over the L3-L4 level revealed severe PV that proved to be the likely etiology of the right-sided paraspinal muscle abscess, infected right L3-L4 facet joint, and SEA. At surgery, the foci of infection were excised/decompressed, and cultures grew methicillin-susceptible Staphylococcus aureus. Following surgery, the patient was improved and was treated with appropriate antibiotic therapy.

Conclusion: PV caused a L3-L4 epidural spinal abscess and cauda equina compression in a 31-year-old male who was successfully treated with operative decompression and appropriate antibiotic management.

Keywords: Epidural abscess, Facet joint arthritis, Methicillin-susceptible Staphylococcus aureus, Paraspinal muscle abscess, Psoriasis vulgaris

INTRODUCTION

Psoriasis vulgaris (PV) affects 85–90% of patients with psoriasis; it is the most common phenotype of atopic dermatitis. PV typically involves extensor surfaces of the elbows, knees, sacral region, and scalp. Here, a 31-year-old male with PV over the L3-L4 lumbar level presented with a cauda equina syndrome attributed to a L3-L4 spinal epidural abscess (SEA).

CASE DESCRIPTION

A 31-year-old male presented with one week of lower back pain, fever, bilateral lower extremity numbness, and one day of paraplegia with loss of sphincter function (i.e., cauda equina syndrome). The lumbar magnetic resonance (MR) documented an enhancing right paraspinal abscess that extended into the right L3-L4 facet joint and spinal epidural compartment[ 1 ] [ Figure 1 ]. The patient’s white blood cell count was elevated (i.e., 12770, neutrophils 81.1%), as was his C-reactive protein (11.57); interestingly, the blood cultures were negative.

Figure 1:

Lumbar magnetic resonance imaging showed an abnormal intensity lesion in the bilateral paraspinal muscle, especially at the right side (white arrow), in the L3/4 right facet joint (white arrow head), and epidural space (black narrow).

Surgery

The incision for the laminectomy extended directly through the large erythematous skin lesion containing a small exudate (i.e., later diagnosed as PV) [ Figure 2 ]. Evidence of infection involved the right paraspinal muscles right L3-L4 facet joint, and extended into the epidural compartment (i.e., abscess). Cultures confirmed a methicillin-susceptible Staphylococcus aureus (MSSA) organism that was treated with four weeks of intravenous minomycin and followed by oral minomycin for two weeks (i.e., until the C-reactive protein level normalized [0.25]).

Figure 2:

We found a skin lesion on the patient’s lower back. It was a large erythema with a small amount of exudate. There was no apparent fistula, but an inflammatory state was suspected. This lesion was diagnosed as psoriasis vulgaris by a dermatologist, which was severe but improved with topical medication.

Postoperative course

Postoperatively, the patient’s lower extremity motor function improved to nearly normal (i.e., 4/5 level). Two weeks postoperatively, the lumbar MR showed no residual L3-L4 epidural abscess. Six months after surgery, the patient was neurologically intact [ Table 1 ].

Table 1:

Symptom changes from preoperative to postoperative.

DISCUSSION

Few studies report SEAs attributed to infection [ Table 2 ].[ 2 , 3 , 5 , 7 ] Park et al. cited a case in which the patient had an epidural abscess with extension into the paraspinal muscles.[ 6 ] Unnikrishnan et al. reported an elderly woman with diabetes and psoas/paraspinal muscle abscesses secondary to a urinary infection.[ 8 ] Kiymaz and Demir reported a child with very large paraspinal and epidural abscesses attributed to a localized streptococcal skin infection of the neck.[ 4 ] Here, a 31-year-old male with a localized L3-L4 level PV skin lesion developed an infection involving the right paraspinal muscles, the right L34 facet, and spinal epidural compartment (i.e., abscess) that required operative decompression/resection and appropriate follow-up antibiotic therapy for MSSA.

Table 2:

A summary of the literatures reporting on paraspinal muscle abscess, spinal epidural abscess, and facet joint arthritis.

CONCLUSION

PV caused a L3-L4 epidural spinal abscess that was quickly diagnosed, decompressed, and treated with appropriate antibiotic therapy.

Ethical approval

The Institutional Review Board approval is not required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

References

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