PMC4352647_01
An epidural mass was observed as a mildly hyper-intense signal on the T1-weighted (a), iso-intensity signal on the T2-weighted (b), and a mildly hyper-intense signal on the fat-suppressed T2-weighted image (c, arrowheads). Furthermore, mildly hyper-intense signals in the posterior ligament complex on the fat-suppressed T2-weighted image indicated the presence of aging blood (c, arrows). On axial view (L2-L3 disk level), a mixed intensity signal on the T1-weighted (d) and an iso-intensity signal on the T2-weighted image (e) was shown to compress the dura (arrows)
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F1
MRI of the lumbar spine revealed an epidural mass over the L2-L4 spinous process, which was observed as a mildly hyper-intense signal on the T1-weighted image (T1WI), an iso-intense signal on the T2WI, and a mildly hyper-intense signal on the fat-suppressed T2WI [Figure 1a-c]. Furthermore, mildly hyper-intense signals were noted in the posterior ligament complex of the L1 and L2 on the fat-suppressed T2WI [Figure 1c]. Because neural compression by the epidural mass seemed to be minimal on axial images of the MRI [Figure 1d and e], the patient underwent conservative management including bed rest and steroid pulse therapy: A 1000 mg intravenous bolus of methylprednisolone was administered on the 1st hospital day, followed by a 500 mg bolus on the second and 3rd hospital day.
(a and b) Macroscopic photographs of the autopsy specimen. Both the spinal column (a) and brain (b) were covered with thick pus. (c) An immunohistochemical photomicrograph showing a cluster of round cells positive for pneumococcal anti-gen, establishing a diagnosis of pneumococcal meningoencephalitis (Original magnification: x100)
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F2
An autopsy was granted, which revealed massive pus accumulation and hemorrhage both in the lumbar epidural space and brain [Figure 2a and b]. Immunohistochemistry of the spinal cord section revealed many round cells positive for pneumococcal anti-gen [Figure 2c], establishing a postmortem diagnosis of fulminant pneumococcal meningoencephalitis that evolved from SEH.