spinal epidural abscess ( sea ) is a rare severe infection and accounts for 2.53.0 cases per 10,000 admissions in general hospitals .
several sea risk factors , such as injection - drug use , diabetes mellitus , and several illnesses have been identified , however , no report has described sea associated with abortion .
we report a case of post - abortion sea caused by the bacteroides fragilis group , which was managed successfully with antibiotics and surgical drainage .
a 30-year - old woman was transferred to our hospital for fever and posterior cervical pain .
two weeks before admission , dilation and curettage ( d and c ) under intravenous anesthesia was performed for incomplete abortion .
after d and c , her obstetrician prescribed ampicillin ( 750 mg / day ) , however , she took them only one day .
three days later , she developed posterior cervical pain , which worsened and caused difficulty in flexing and extending the neck .
ten days after the operation , she was admitted to the emergency department of another hospital .
physical examination revealed body temperature of 39.3c ; blood pressure , 147/91 mmhg ; pulse , 101 beats / min ; and respiratory rate , 18 breaths / min .
she experienced severe pain and stiffness in the neck . neither abdominal nor pelvic signs were seen .
her leukocytes were elevated to 8100/l and the c - reactive protein ( crp ) was positive .
physical examination revealed mild weakness in the right upper limb [ medical research council ( mrc ) grade 4 ] ; deep tendon reflexes were slightly decreased .
the liver - function test results and electrolyte levels were normal ; however , leukocytes had elevated to 8400/l , and the crp level had elevated to 9.87 mg / dl .
she was seronegative for hepatitis b virus surface antigen , and hepatitis c virus and human immunodeficiency virus ( hiv ) antibodies .
analysis showed elevated cell count ( 266/l ) and total protein concentration ( 1,311 mg / dl ) .
chest radiography revealed normal results , and a transthoracic echocardiography showed no vegetation on the valves .
magnetic resonance imaging ( mri ) of the cervical spine showed infectious spondylodiscitis at the c5/c6 level and anterior epidural abscesses at c4-th3 with spinal cord compression [ figure 1 ] .
sagittal t2-weighted image shows an anterior epidural mass associated with c5 spondylodiscitis at the c4-th3 level intravenous injections of ampicillin ( 12 g / day ) and ceftriaxone ( 4 g / day ) , and hyperbaric oxygen therapy were administered .
seven days after admission , weakness in the right upper and lower limbs increased ( mrc grade 2 ) and the numbness extended to the right lower limb .
mri showed enlarged epidural abscesses and increased spinal cord compression ; therefore , urgent orthopedic surgery was performed .
after the anterior discectomy of c5 and c6 , pus was drained . since pus culture revealed b. fragilis group , oral metronidazole ( 1 g / day )
the weakness in her limb muscles were improved ( mrc grade 4 ) , and the numbness gradually resolved after the operation .
in most causes of sea , at least one predisposing factor such as intravenous drug use , diabetes mellitus , invasive spinal procedures , penetrating spinal trauma , and immunosuppressive therapy is present ; however , d and c for abortion as one of the risk factors for sea has not reported previously .
bacteremia occurs in approximately 5% of the patients who undergo d and c , and progresses to intrauterinal abscess in most cases .
however , some forms of extrauterinal abscess after d and c , such as anaerobic breast abscess , septic arthritis and thigh abscess caused by -haemolytic streptococci , psoas abscess caused by staphylococcus aureus and bacterial sacroliliitis and gluteal abscess caused by streptococcus agalactiae have been rarely reported .
these manifestations were not associated with any underlying diseases , and most of them eventually required surgical drainage .
although the role of antimicrobial prophylaxis in postprocedural pelvic inflammatory disease prevention has been extensively discussed , there is no evidence supporting the use of antibiotics for subacute bacterial endocarditis prophylaxis .
a large variety of causative agents for sea have been indentified ; however , two - thirds of the causes of pyogenic bacteremia were caused by staphylococcus aureus , and only 2% of the cases were caused by anaerobic bacteria .
the b. fragilis group , which includes organisms such as b. fragilis , b. ovatus , b. thetaiotaomicron , b. uniformis , and b. vulgatus , contains anerobic bacteria .
these bacteria can produce a wide variety of infections with a tendency to form abscesses .
female genital tract infections caused by these bacteria include bacterial vaginosis , endometritis , and postsurgical obstetric and gynecologic infections . on the other hand , except for
extragenital procedures involving d and c , endodonic procedure and vertebroplasy might be one of the risk factors of anerobic spondylodiscitis , which were resulted from hematogenous spreading from a distant primary site of infection .
in our case , d and c for incomplete abortion might have caused transient bacteremia resulted in spondylodiscitis and hematogenous sea .
micro - organism in vagina might reach cervical discs through hematogenous spreading from pelvic venous plexus ( batson 's plexus ) and cause spondylodiscitis and sea in early days .
the patient did not have any risk factors other than the d and c procedure .
early imaging could play a crucial role in the treatment of sea , and a careful history taking and physical examination could allow detection of the infectious source . although the use of prophylactic antibiotics in intrauterinal procedures and in cases of incomplete abortion is controversial at present , further clinical trials to assess the necessity of antibiotic prophylaxis after d and c for abortion is necessary should be considered .
 spinal epidural abscess ( sea ) is a rare infection complicated in patients who have some risk factors such as injection - drug use , diabetes mellitus , and several illnesses . 
 however , no case of sea associated with abortion has been reported . here 
 we report a case of sea in a 30-year - old woman after dilation and curettage for incomplete abortion . 
 the diagnosis of sea was done by mri and pus was drained after the cervical discectomy . 
 bacteroides fragilis group was cultured from the aspirated pus sample . 
 the patient responded to surgical drainage and antibiotics . 