Spinal epidural abscess (SEA) is a rare, yet serious neurologic emergency that could result in irreversible disability. The classic clinical presentation comprises a triad of fever, back pain, and other neurologic complaints (weakness, bowel/bladder dysfunction). We report a case with an atypical presentation of SEA that lacked classic clinical features on initial presentation.

69-year-old female with past medical history of AML (on clinical trial) presented to the ED with left upper extremity pain following COVID vaccination, and (presumably related) focal weakness. Initial exam revealed more extensive weakness affecting the left lower extremity as well, prompting a comprehensive stroke work-up including MRI brain w/wo gadolinium and vessel studies which were unremarkable. The following day, the symptoms progressed from a grossly 3/5 motor strength on the left to a 1/5 of all extremities, with no withdrawal to noxious stimuli. Reflexes diffusely absent with exception to trace bilateral brachioradialis and left patellar. The patient began to manifest mild encephalopathy in the setting of low-grade neutropenic fever. Empiric broad spectrum antibiotics with CNS coverage was initiated. CSF was significant for WBC 500 with a neutrophilic predominance, protein 200, and glucose <20. MRI of the neuroaxis revealed an extensive peripherally enhancing collection spanning from C2-C6, suspicious for a large cervical spinal abscess. The abscess was surgically evacuated the following day with a significant improvement in the motor exam (grossly 2-3/5 in the upper extremities and 3-4/5 in the lower extremities).

This case was significant due to the atypical presentation (unilateral involvement and hyporeflexia) along with lack of findings on history (back pain) that might suggest spinal etiology. Clinicians should maintain a high index of suspicion for spinal etiology especially in neutropenic patients, as timely intervention can avoid irreversible paralysis and disability.