case_images: PMC4352647_01
case_images: 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)
case_images: AJNS-10-58b-g001.jpg
case_images: PMC4352647_01_AJNS-10-58b-g001.jpg
case_images: F1
case_images: 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.
case_images: (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)
case_images: AJNS-10-58b-g002.jpg
case_images: PMC4352647_01_AJNS-10-58b-g002.jpg
case_images: F2
case_images: 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.