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Lumbosacral Epidural Abscess Due To Hidradenitis Suppurativa

University of North Carolina School of Medicine Chapel Hill, NC 27599

Hidradenitis suppurativa (also known as acne inversa, acne tetrad, and pyoderman fistulans) is a rare disorder usually found in women [1]. Hidradenitis suppurative is characterized by recurrent chronic skin infections and the formation of sinus tracts and considerable scars. Its most common locations are the axillae and anogenital regions. We present the MR imaging findings in a patient with hidradenitis suppurativa resulting in lumbosacral epidural abscesses.

A 48-year-old woman with a history of diabetes mellitus presented with 4 weeks of lower back pain, fevers, chills, and numbness in the lower extremities. Physical examination showed a sacral decubitus ulcer and associated hidradenitis suppurative. MR imaging of the region showed an abnormal enhancing soft-tissue mass surrounding the sacrum, extending into the left lower lumbar paraspinal region, and in continuity with the site of the decubitus ulcer. The abnormal soft-tissue extended into the spinal region via the left L5-S1 foramen (Fig. 3A,3B,3C). The epidural space at the level of the sacrum and lower lumbar region showed abnormal enhancing soft tissue with compression of the thecal sac. Additionally, the bone marrow signal intensity at L5 and S1 was abnormal, suggesting osteomyelitis. The patient was taken to the operating room where after L5 and S1 laminectomies, frank pus was found in the epidural space. The patient was discharged 5 days later on IV antibiotics.

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —48-year-old woman with history of diabetes mellitus who presented with 4 weeks of lower back pain, fevers, chills, and numbness in lower extremities. Unenhanced T1-weighted MR image shows abnormal soft-tissue mass in left paraspinal region extending into left L5-S1 neural foramen and into epidural space.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —48-year-old woman with history of diabetes mellitus who presented with 4 weeks of lower back pain, fevers, chills, and numbness in lower extremities. Corresponding enhanced T1-weighted MR image shows that although most of abnormality enhances, central portion of its epidural component does not and suggests abscess.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C. —48-year-old woman with history of diabetes mellitus who presented with 4 weeks of lower back pain, fevers, chills, and numbness in lower extremities. Midsagittal T2-weighted MR image shows abnormal and patchy signal intensity in spinal canal at level of L5 and sacrum. Bone marrow at level of L5 and sacrum also shows abnormal high signal intensity.

Hidradenitis suppurativa is a misnomer because the process does not arise from the sweat glands, as implied, but from infected hair follicles. It is presumed that hidradenitis suppurative is a response to follicular occlusion probably caused by frictional trauma [2]. Sinus tract formation arises from the rupture of the follicular epithelium containing an abscess. These sinus tracts may dissect into deeper structures such as muscles, fascia, and even bowel [3]. The treatment of hidradenitis suppurative is difficult. Topical and systemic antibiotics are indicated as is surgery. Even after appropriate therapies, recurrences occur in up to 25% of patients [4]. In our patient, the extensive involvement caused by hidradenitis suppurative was probably complicated by her diabetes mellitus. The association between diabetes mellitus and hidradenitis suppurative, however, has not been definitively established.

References

1. Jemic GB, Heidenhaeim M, Nielson NH. The prevalence of hidradenitis suppurative and its potential precursor lesions. J Am Acad Dermatol 1996;35:191 -194[Medline]
2. Jansen T, Plewig G. What's new in hidradenitis inversa (alias hidradenitis suppurativa)? J Eur Acad Dermatol Venereol 2000;14:342 -343[Medline]
3. Mortimer PS, Lunniss MS. Hidradenitis suppurativa. J R Soc Med 2000;93:420 -421[Free Full Text]
4. Ritz P, Runkkle N, Haier J, Buhr HJ. Extent of surgery and recurrence of hidradenitis suppurativa. Int J Colorect Dis 1998;13:164 -168[Medline]

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