Epidural abscess differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]; Anthony Gallo, B.S. [3]

Overview

Intracranial epidural abscess must be differentiated from epidural hematoma, subdural empyema, brain abscess, tuberculous meningitis, and other intracranial mass lesions. Spinal epidural abscess must be differentiated from other conditions that cause back pain, motor weakness, and/or spinal tenderness, such as arthritis, osteoarthritis, intervertebral disc disease, vertebral osteomyelitis, primary or metastatic tumors, and musculoskeletal pain.

Differential Diagnosis

Intracranial Epidural Abscess

Intracranial epidural abscess must be differentiated from other diseases that cause headache, vomiting, fever, altered mental status, seizures, cranial nerve abnormalities, and paresis. Intracranial epidural abscess must be differentiated from:

Disease	Findings
Hematoma	Presents with a collection of blood, bruise (if it occurs near the skin). If it occurs near the brain, it may act as a mass effect, and the patient may present with increased intracranial pressure, midline shift, and brain herniation.
Epidural hematoma	Presents with a collection of blood in the epidural space, headache, back pain, confusion, weakness, and focal neurologic signs.
Subdural empyema	Presents with a collection of purulent material accumulating in the subdural space, mass effect, fever, headache, altered mental status, and seizures.
Brain abscess	Presents with a collection of purulent material within the brain tissue, confusion, decreased movement, decreased sensation, decreasing responsiveness, drowsiness, fever, headache, loss of coordination, nausea, seizure, and vomiting.
Chronic meningitis	Presents with inflammation of the meninges, headache, nuchal rigidity, fever, and altered mental status.
Ebola	Presents with fever, chills vomiting, diarrhea, generalized pain or malaise, and internal and external bleeding, that follow an incubation period of 2-21 days.
Lassa fever	Disease onset is usually gradual, with fever, sore throat, cough, pharyngitis, and facial edema in the later stages. Inflammation and exudation of the pharynx and conjunctiva are common.
Yellow fever and other Flaviviridae	Present with hemorrhagic complications. Epidemiological investigation may reveal a pattern of disease transmission by an insect vector. Virus isolation and serological investigation serves to distinguish these viruses. Confirmed history of previous yellow fever vaccination will rule out yellow fever.
Shigellosis & other bacterial enteric infections	Presents with diarrhea, possibly bloody, accompanied by fever, nausea, and toxemia, vomiting, cramps, and tenesmus. Stools contain blood and mucous in a typical case. A search for possible sites of bacterial infection, together with cultures and blood smears, should be made. Presence of leucocytosis distinguishes bacterial infections from viral infections.
Ebola	Presents with fever, chills vomiting, diarrhea, generalized pain or malaise, and internal and external bleeding, that follow an incubation period of 2-21 days.
Others	Scarlet fever, leptospirosis, viral hepatitis, typhus, and mononucleosis can produce signs and symptoms that may be confused with rheumatic fever in early stages of infection.

• Chronic meningitis - c
• Tuberculous meningitis - consists in the inflammation of the meninges, caused by the organism Mycobacterium tuberculosis. Fever and headache are the cardinal symptoms however, other symptoms such as confusion and focal neurologic signs may also be present, making tuberculous meningitis an important element of the differential diagnosis.

• Primary parenchymal tumor - consists in any intracranial tumor located, and with its origin, in the brain parenchyma. Although they can be located anywhere in the brain parenchyma, in children they are commonly located in the posterior cranial fossa, while in adults, they can affect any part of the brain. Because of the different locations brain parenchymal tumors may take, there may also be many different signs and symptoms. These include: focal neurologic signs, increasing intracranial pressure and seizures.
• Metastatic tumor - consists in any intracranial tumor, which has spread from another organ or tissue, making the brain tumor, a secondary tumor. Depending on the location of the brain affected, there will be different signs and symptoms. These may include: focal neurologic signs, increasing intracranial pressure, seizures and others, which may mimic signs and symptoms from epidural abscess.
• Meningioma - consists in a tumor arising from the arachnoidal cap cells of the meninges. In 95% of the cases it's a benign tumor. Depending on the size and location of the tumor, different areas of the brain may be affected, therefore it may manifest itself with different signs and symptoms, including focal neurologic signs, increasing intracranial pressure and seizures. Since these are shared with epidural abscess, this condition should be in the differential diagnosis.

• Cranial arteritis - or temporal arteritis is an inflammation of the blood vessels of the head, commonly the large and medium arteries. Among others, it may manifest with fever, headache and focal neurologic signs, making it an important element of this differential diagnosis

Spinal Epidural Abscess

At the time of presentation, the diagnosis of spinal epidural abscess is only suspected in 40% of the cases. This is due to the fact that there are several other conditions, more common than this type of abscess, presenting with similar signs and symptoms. Spinal epidural abscess usually presents with back pain, fever, motor weakness, and spinal tenderness. Therefore, the differential diagnosis includes:

• Musculoskeletal pain - can be related to several other diseases, however it can be an entity in itself, following overuse and over stretching of muscles, or in the context of a viral infection. When located in the lower back, it may be included in the differential diagnosis of epidural abscess, since this is one of the possible symptoms of this condition.
• Arthritis - despite the many types of arthritis, osteoarthritis, also known as degenerative joint disease, is the most common form and may result from trauma, infection or be a result of aging. It may be responsible for back pain or stiffness which, since are also possible presentations of epidural abscess, justify the inclusion of this condition in the differential diagnosis.
• Degenerative bone disease - may include several conditions of the bone. The common ground is the weakening of the bone structure, such as in osteoporosis which, among others, may cause lower back pain or tenderness and weakness. Since these symptoms may be present in epidural abscess as well, this condition should be part of the differential diagnosis.
• Intervertebral disc disease - degenerative disc disease is a common disorder of the lower spine, in which disc degeneration may lead to spinal stenosis, spondylolisthesis and osteoarthritis. These conditions may be manifested by lower back pain, weakness and tenderness, which explain why this condition should be included in the differential diagnosis.
• Sciatica secondary to disc herniation - consists in a condition affecting the spine, in which a tear in the outer annulus fibrosus of an intervertebral disc allows the soft central nucleus pulposus to bulge out. This tear may cause an inflammatory reaction, which will cause severe pain, even in the absence of spinal compression. It may be manifested by: lower back and leg pain, sensory changes, such as tingling, numbness, and reflex changes. Since some of these signs and symptoms are shared with epidural abscess, it should be part of the differential diagnosis.
• Epidural hematoma - consists in the buildup of blood in the epidural space, between the dura mater and the inner bone surface of the skull or spinal canal. It may cause headache or back pain, depending on the location of the hematoma, confusion, weakness, focal neurologic signs and others. Since many of this signs and symptoms are shared with the epidural abscess, this conditions should be included in the differential diagnosis.
• Meningitis - consists in the inflammation of the meninges, as a response to infectious agents, certain drugs, trauma or cancer. The inflammatory process will cause signs and symptoms such as headache, back pain, nuchal rigidity, fever and altered mental status, which are similar to those of epidural abscess, and why meningitis should be on the differential diagnosis.
• Bone tuberculosis - a presentation of extrapulmonary tuberculosis, affecting the bones, most often the spine (Pott's disease, at the level of lower thoracic and upper lobar vertebrae. It results from an hematogenous spread of the organism from other sites, commonly the lung. It may have various signs and symptoms, from which back pain, fever and weakness are common to the epidural abscess, making this an important element of the differential diagnosis.Template:Seealso
• Vertebral osteomyelitis - consists in an infection of the bone and bone marrow, concentrated in the spinal region. It may affect two vertebrae and the disc in between and therefore be responsible for the narrowing of the space between the two. The disease may be acute or chronic, however it is more commonly known to be an acute condition. It may manifest with: fever, back pain, swelling, weakness of the vertebral column and surrounding muscles and night sweats. Since some of the symptoms are shared with epidural abscess, this conditions should be in the differential diagnosis.
• Primary or metastatic tumor - consists in any tumor arising from the spinal cord, or elsewhere in the body, which metastasises to the spinal cord. Depending on its location, it may be classified as: extradural, intramural or intramedullary spinal tumor. It will create a mass effect, which will compress the spinal cord and weaken the vertebral structure, causing signs and symptoms, such as: incontinence, weakness in the saddle area and back pain. Therefore it should also be included in this differential diagnosis.
• Leukemia - cancer of the blood or bone marrow, characterized by an abnormal proliferation of blood cells, usually leukocytes. Among other signs and symptoms, it may present with bruises, dyspnea, fever, chills, weakness and fatigue, headache and other neurologic symptoms, bone and joint pain. Since some of these are common with epidural abscess, this condition should be included in the differential diagnosis.
• Herpes zoster - (before appearance of skin lesions) commonly known as shingles, consists of a viral disease, characterized by a painful skin rash with blisters on a limited area, usually unilateral, often in a stripe pattern. Signs and symptoms may include fever, headache, chills and tingling sensations. Since some of these are shared with epidural abscess, this condition should be in the differential diagnosis.
• Spinal cord ischemia - consists in the deprivation of blood of a part of the spinal cord. It may arise in numerous settings, namely thrombotic events, following trauma, compression of the arteries from a mass, which can be from an hematoma, abscess, tumor or bone structure. This deprivation can cause different signs and symptoms, depending on the area of the spinal cord affected, such as: radiculopathy, weakness and pain. Since these are shared with epidural abscess, this condition should be included in the differential diagnosis.