Multilevel Cryptogenic Intramedullary Cord Abscesses: A Multimodality Approach

Background: Intramedullary spinal cord abscesses are rare, life-threatening infections that are diagnostically challenging, particularly in patients without predisposing conditions.

Case Presentation: A previously healthy 49-year-old woman presented with acute cervicalgia, progressive paresis, mild leukocytosis, and subjective fever. Unenhanced cervical, thoracic, and lumbar computed tomography (CT) demonstrated moderate spondylosis and cervical canal narrowing. Head, neck, and chest CT angiography excluded aortic dissection. Following admission, she rapidly deteriorated to flaccid quadriparesis, prompting magnetic resonance imaging (MRI).

Imaging Findings: MRI demonstrated two intramedullary lesions involving the medulla oblongata and C3–C4, with peripheral ring enhancement and extensive cervicothoracic cord edema. Marked restricted diffusion on diffusion-weighted imaging (DWI) suggested pyogenic abscesses. Neurosurgical drainage confirmed purulent material, and cultures grew Streptococcus intermedius and Staphylococcus caprae. Positron emission tomography-computed tomography (PET-CT) revealed no occult infectious source. Serial MRI monitored therapeutic response. Despite functional improvement, the patient continues rehabilitation for residual paraparesis.

Conclusion: This case highlights the limitations of CT in rapidly progressive flaccid paralysis and the importance of early MRI with DWI in acute myelopathy. Restricted diffusion was crucial for distinguishing intramedullary abscesses from neoplastic lesions. A multimodality approach facilitates timely diagnosis, treatment monitoring, and evaluation for an underlying infectious source.