We present a case of streptococcus intermedius encephalomyelitis presumably precipitated post-inoculation due to fine needle aspiration of paratracheal lymphadenopathy.

A 49 year-old immunocompetent man presented with two days of paraplegia, back pain, and urinary retention. Three weeks prior to presentation, he had an endobronchial ultrasound and fine needle aspiration for incidentally noted paratracheal lymphadenopathy, results of which had been unremarkable. Initial examination revealed paraplegia, bilateral positive Babinski, and T5 sensory level. Neuroimaging revealed multiple supratentorial ring-enhancing lesions and enhancing intramedullary lesions at C2-C3 and T3-T4 with associated vasogenic edema. CSF opening pressure was 20 cm of H2O with 38 monocyte-predominant nucleated cells, protein of 333, and normal glucose. Initial suspicion favored malignancy or demyelinating disease, and dexamethasone was started. His exam worsened with paresis of arms, and repeat MRI demonstrated new enhancing lesions at C6-T1 with worsening vasogenic edema extending to the conus. Emergent stereotactic brain biopsy and frozen section was suspicious for abscess; he thus received C2 myelotomy with copious purulent drainage.  Final cultures confirmed streptococcus intermedius; after 12 weeks of intravenous ceftriaxone there was recovery of arm strength, although he remained paraplegic.

This case involves a rare presentation of concomitant brain and intramedullary streptococcal abscesses, to our knowledge not previously reported in the literature. The mechanism of transmission was possibly iatrogenic in the setting of fine needle aspiration. Rapid decline with steroids increased suspicion for infectious etiology. We further discuss an approach to management including prompt initiation of antibiotic therapy and the role of biopsy for diagnosis and treatment.