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J Neurosci Rural Pract 2019 Jan-Mar;10(1):148-150

Department of Neurosciences, Hospital Aleman, Buenos Aires, Argentina.

The authors describe a case of infratentorial epidural abscess caused by community-associated methicillin-resistant (CA-MRSA) in a patient with a recent history of cutaneous furunculosis. This 29-year-old male presented with an occipital headache associated with fever, vomiting, and neck stiffness. Admission magnetic resonance imaging showed a retrocerebellar epidural abscess. Read More

Spine J 2019 Feb 11. Epub 2019 Feb 11.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School. Electronic address:

Background Context: Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio have been previously identified as markers for overall survival in oncology but remain heretofore unexplored in spinal epidural abscess (SEA).

Purpose: The purpose of this study was to determine the impact of these routinely collected assessments on ninety-day mortality in SEA.

Study Design/setting: Retrospective, case-control study PATIENT SAMPLE: Patients 18 years or older diagnosed with SEA at two academic medical centers and three community hospitals OUTCOME MEASURES: Ninety-day post-discharge and in-hospital mortality METHODS: Complete blood count with differential obtained on the day immediately preceding or on the day of admission was used to calculate platelet to lymphocyte and neutrophil to lymphocyte ratios. Read More

Eur J Case Rep Intern Med 2017 2;4(8):000694. Epub 2017 Aug 2.

Division of Urology, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.

A 71-year-old man presented with spondylodiscitis with epidural and psoas muscle abscesses following transrectal ultrasound (TRUS)-guided prostate biopsy. These rare complications were detected by computed tomography of the abdomen and magnetic resonance imaging of the lumbar spine. The patient was successfully treated with antibiotics and underwent neurosurgery. Read More

World Neurosurg 2019 Feb 8. Epub 2019 Feb 8.

Sunnybrook Health Sciences Centre, Division of Neurosurgery, University of Toronto, Toronto ON, Canada.

Background: Acupuncture is a common form of alternative medicine that is utilized for pain control, amongst other modalities of treatment. It is a relatively safe procedure but complications, including those of infectious aetiology, may still occur.

Case Description: A 47-year-old, immunosuppressed, female patient presented with fever, altered level of consciousness, dysphasia, and a left occipital subgaleal fluctuant mass following acupuncture for headaches in the same area. Read More

Oper Neurosurg (Hagerstown) 2019 Feb 5. Epub 2019 Feb 5.

Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.

Background And Importance: Although many studies have demonstrated the biomechanical superiority of cervical pedicle screw (CPS) placement with sufficient safety and accuracy, it also has an inevitable major drawback in that an extensive posterior neck muscle dissection results in immediate postoperative neck pain. To avoid this disadvantage and highlight the several biomechanical advantages of CPS, we conducted the first minimally invasive surgery using both a tubular retractor through the posterolateral approach and a freehand placement technique.

Clinical Presentation: A 77-yr-old man presented with quadriparesis and neck pain. Read More

Medicine (Baltimore) 2019 Feb;98(5):e14196

Department of Orthopedics.

Rationale: Spinal epidural abscess (SEA) is a rare condition that shows a high prevalence in immunocompromised patients. The clinical presentation of SEA includes the "classic triad" of pain, fever, and neurological dysfunction. However, these nonspecific features can lead to a high rate of misdiagnosis. Read More

J Clin Neurophysiol 2019 Jan 28. Epub 2019 Jan 28.

Departments of Clinical Neurophysiology and.

Purpose: Monitoring of somatosensory evoked potentials (SSEPs) serves as an early warning system to detect spinal cord injury and is correlated with postoperative sensory findings. It is an indirect indicator of motor function. This study aimed to evaluate the usefulness of intraoperative SSEPs monitoring as a stand-alone tool during spinal surgeries when motor evoked potentials are not available, to prevent and predict new postoperative neurologic deficits. Read More

Int J Infect Dis 2019 Jan 23. Epub 2019 Jan 23.

Zhejiang-California International Nanosystems Institute, Zhejiang University, Hangzhou, China; Department of Pathology and Laboratory Medicine, UCLA School of Medicine, Los Angeles, CA, USA. Electronic address:

We report a rare case of culture negative L4-L5 discitis and epidural abscess in an immunocompetent child who had dry cupping therapy performed to treat low back strain. The causative pathogen was identified as Stenotrophomonas maltophilia by shotgun metagenomic sequencing of spinal cord aspirate after more than one month of unsuccessful empirical treatment with 6 different antibiotics. The patient was successfully treated with Sulfamethoxazole-trimethoprim and minocycline. Read More

Ceylon Med J 2018 12;63(4):190-191

Teaching Hospital Karapitiya, Sri Lanka.

Clin Case Rep 2019 Jan 20;7(1):229-230. Epub 2018 Nov 20.

Department of Internal Medicine, Hurley Medical Center Michigan State University Flint Michigan.

New onset low back pain which is recalcitrant to usual treatment should be evaluated aggressively even in the absence of fever or neurologic deficits. Corticosteroids given for back pain will accelerate occult spinal infection and may mask symptomatology leading to more severe disease. Read More

Cochrane Database Syst Rev 2019 01 16;1:CD012819. Epub 2019 Jan 16.

Department of Anesthesiology, Faculty of Medicine, University of Sherbrooke, Sherbrooke, Quebec, Canada.

Background: Spine surgery may be associated with severe acute postoperative pain. Compared with systemic analgesia alone, epidural analgesia may offer better pain control. However, epidural analgesia has sometimes been associated with rare but serious complications. Read More

Int J Infect Dis 2019 Jan 11. Epub 2019 Jan 11.

Department of Clinical Microbiology, Aarhus University Hospital, Aarhus, Denmark.

MRSA CC398 has spread from pigs to humans but rarely from person to person, and has been considered less virulent than other MRSA strains. Livestock-associated methicillin-resistant Staphylococcus aureus clonal complex 398 (LA-MRSA CC398) is known to colonize especially pig farmers. Recent studies show an increased number of people colonized with LA-MRSA CC398 and invasive infections caused by LA-MRSA CC398. Read More

J Med Case Rep 2019 Jan 8;13(1). Epub 2019 Jan 8.

Orthopaedics Department, Universiti Malaysia Sarawak, 94300, Kota Samarahan, Sarawak, Malaysia.

Background: Gout is a monosodium urate deposition disease which is prevalent worldwide. The usual manifestations are crystal arthropathy and tophi deposition in the soft tissues. Spinal tophi may also occur and are rarely reported, resulting in various clinical manifestations such as back pain, spinal cord compression, radiculopathy, and even mimicking epidural abscess and spondylodiscitis. Read More

Int J Spine Surg 2018 Dec 21;12(6):743-750. Epub 2018 Dec 21.

Department of Orthopaedic Surgery, Rehovot, Israel.

Background: The study aimed to assess the effectiveness of antibiotic treatment for spondylodiscitis, its failure rates, and the need for surgical intervention.

Methods: This is a retrospective study of patients who presented with spontaneous deep spinal infections and spondylodiscitis between 2011 and 2013. Clinical, bacteriologic, and radiographic data during hospitalization were analyzed. Read More

Neurosurg Focus 2019 Jan;46(1):E4

1Department of Neurosurgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana; and.

OBJECTIVEFew studies have been published specifically examining intravenous drug abuse (IVDA)-associated spinal epidural abscesses (SEAs), an unfortunate sequela of the opioid crisis in the United States. Here, the authors examined a series of patients with IVDA-associated SEAs in order to shed light on this challenging disease entity.METHODSThis study is a retrospective chart review of patients presenting with IVDA-associated SEAs at the authors' institution from 2013 to 2018, spanning the statewide implementation of opioid-prescribing restrictions. Read More

J Neurosurg 2019 Jan 4:1-7. Epub 2019 Jan 4.

1Department of Neurological Surgery.

OBJECTIVEA short-term lumbar drain (LD) trial is commonly used to assess the response of normal pressure hydrocephalus (NPH) patients to CSF diversion. However, it remains unknown whether the predictors of passing an LD trial match the predictors of improvement after ventriculoperitoneal shunting. The aim of this study was to examine outcomes, complication rates, and associations between predictors and outcomes after an LD trial in patients with NPH. Read More

Acta Neurochir Suppl 2019 ;125:345-353

Spine Surgery Division, Agostino Gemelli Hospital, Catholic University of the Sacred Heart of Rome, Rome, Italy.

Purpose: An extensive spinal epidural abscess is a rare condition and causes significant morbidity and mortality. Few authors have described this uncommon entity, which requires early diagnosis and optimal treatment to avoid devastating complications. The purpose of this study was to evaluate a minimally invasive technique for treatment of an extensive spinal epidural abscess by describing two cases. Read More

Diagn Microbiol Infect Dis 2018 Dec 4. Epub 2018 Dec 4.

Division of Infectious Diseases, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Republic of Korea. Electronic address:

Objectives: Functional disability may persist after completing treatment for hematogenous pyogenic vertebral osteomyelitis (HPVO). The objective of this study was to identify factors associated with residual sequelae after treatment of HPVO.

Methods: We conducted a retrospective study of patients diagnosed with HPVO at 5 tertiary-care hospitals between January 2005 and December 2012. Read More

Clin Spine Surg 2019 Feb;32(1):18-29

Department of Neurological Surgery, Duke University, Durham, NC.

Study Design: This is a meta-analysis.

Objective: Perform a systematic review and quantitative meta-analysis of neurological outcomes from all available spinal epidural abscess (SEA) literature published between 1980 and 2016.

Summary Of Background Data: Current literature on SEAs lacks large-scale data characterizing prognostic factors and surgical indications. Read More

Biomed J 2018 Oct 5;41(5):306-313. Epub 2018 Nov 5.

Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan. Electronic address:

Background: Cervical spine infections are uncommon but potentially dangerous, having the highest rate of neurological compromise and resulting disability. However, the factors related to surgical success is multiple yet unclear.

Methods: We retrospectively reviewed the medical records of 27 patients (16 men and 11 women) with cervical spine infection who underwent surgical treatment at Chang Gung Memorial Hospital, Linkou branch, between 2001 and 2014. Read More

Global Spine J 2018 Dec 13;8(4 Suppl):85S-95S. Epub 2018 Dec 13.

Cleveland Clinic, Cleveland, OH, USA.

Study Design: Systematic review.

Objectives: Spinal epidural abscesses (SEAs) are rare, but when missed or when diagnosis is delayed, SEA can lead to permanent neurological impairment or death. Limited information exists on the optimal treatment modalities for SEA, especially in the lumbar spine. Read More

Global Spine J 2018 Dec 13;8(4 Suppl):68S-84S. Epub 2018 Dec 13.

Cleveland Clinic, Cleveland, OH, USA.

Study Design: Systematic review.

Objectives: Past research has demonstrated increased speed and severity of progression for spinal epidural abscesses (SEAs) of the thoracic level, specifically, when compared with SEAs of other spinal cord levels. Untreated, this infection can result in permanent neurological sequelae with eventual progression to death if inadequately managed. Read More

Global Spine J 2018 Dec 13;8(4 Suppl):59S-67S. Epub 2018 Dec 13.

Thomas Jefferson University, Philadelphia, PA, USA.

Study Design: Systematic analysis and review.

Objective: Evaluation of the presentation, etiology, management strategies (including both surgical and nonsurgical options), and neurological functional outcomes in patients with cervical spinal epidural abscess (SEA).

Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria were used to create a framework based on which articles pertaining to cervical SEA were chosen for review following a search of the Ovid and PubMed databases using the search terms "epidural abscess" and "cervical. Read More

BMC Infect Dis 2018 Dec 20;18(1):686. Epub 2018 Dec 20.

Semmelweis University, Institute of Medical Microbiology, Budapest, Hungary.

Background: Central nervous system (CNS) infections caused by Actinomyces spp. including brain abscess, actinomycoma, subdural empyema and epidural abscess are well described, however reports of Actinomyces-associated meningitis are scarcely reported.

Case Report: We present the case of a 43-year-old Hungarian male patient with poor socioeconomic status who developed acute bacterial meningitis caused by Actinomyces turicensis originating from the left side mastoiditis. Read More

BMJ Case Rep 2018 Nov 28;11(1). Epub 2018 Nov 28.

Departamento de Medicina Interna e Medicina Intensiva, Hospital da Luz Lisboa, Lisboa, Portugal.

Emerg Infect Dis 2019 Jan;25(1):187-189

We report a case of severe disseminated infection in an immunocompetent man caused by an emerging lineage of methicillin-sensitive Staphylococcus aureus clonal complex 398. Genes encoding classic virulence factors were absent. The patient made a slow recovery after multiple surgical interventions and a protracted course of intravenous flucloxacillin. Read More

Medicine (Baltimore) 2018 Dec;97(50):e13272

Division of Pain Medicine, Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medicine, New York, New York.

Rationale: Continuous epidural infusion of local anesthetic may be an alternative to sympathetic blocks in refractory cases of complex regional pain syndrome (CRPS). Spinal epidural abscess (SEA) is a well-known complication associated with this technique, especially in patients with immune deficiencies. We herewith report a cervical SEA associated with an epidural catheter in a woman with CRPS and selective IgG3 subclass deficiency. Read More

Malays Orthop J 2018 Nov;12(3):47-49

Department of Orthopaedics, Catholic University of Sacred Heart, Rome, Italy.

Disc herniation is one of most common causes of spine surgery. Because of the presence of posterior longitudinal ligaments, disc fragments often migrate into the ventral epidural space. A posterior epidural herniation of a disc fragment is a rare occurrence. Read More

Medicine (Baltimore) 2018 Dec;97(49):e13541

Department of Spine Surgery.

Rationale: Nocardial spinal epidural abscess is rare. The diagnosis is often difficult to make and, if delayed, poses a high risk of long-term disability. Nocardial spinal epidural abscess with severe lumbar disc herniation has not previously been reported. Read More

Spine J 2018 Dec 8. Epub 2018 Dec 8.

Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA.

Background Context: A spinal epidural abscess (SEA) is a serious condition that may be managed with antibiotics alone or with decompressive surgery combined with antibiotics.

Purpose: The objectives of this study were to assess the clinical outcomes of SEA after surgical management and to identify the patient-level factors that are associated with outcomes following surgical decompression and removal of SEA.

Study Design/setting: Retrospective chart review analysis. Read More

Spine (Phila Pa 1976) 2018 Dec;43(24):E1454-E1462

Aster MIMS Hospital, Calicut, Kerala, India.

Study Design: A retrospective case series.

Objective: The aim of this study was to report the immunosuppression and secondary bacterial infection after dengue viral infection and the predilection of these infections in the spine. This can trigger further research in to this fact. Read More

eNeurologicalSci 2019 Mar 22;14:1-3. Epub 2018 Nov 22.

Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465, Kajii-chou, Kawaramachi Hirokoji, Kamigyo-ku, Kyoto 602-0841, Japan.

World Neurosurg 2018 Nov 27. Epub 2018 Nov 27.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Background: None of the existing prognostic scoring systems for spinal epidural abscess (SEA) include albumin despite albumin's established role in inflammation, nutrition, lipid peroxidation, and regulation of apoptosis. The purpose of the present study was to determine the prognostic value of albumin in SEA.

Methods: We performed a retrospective, case-control study of 2 independent data sets: patients with SEA in an institutional population and patients in the National Surgical Quality Improvement Program (NSQIP). Read More

Clin Imaging 2018 Nov 15;54:15-20. Epub 2018 Nov 15.

Department of Radiology, University of Florida, Gainesville, FL, United States of America.

Differentiation of bone infarct from osteomyelitis is one of the most challenging issues in the evaluation of acute bone pain in sickle cell patients. The imaging modalities that are currently being used for assessment of bone marrow in this population have several limitations. We present a case of an 18-year-old male with a history of sickle cell disease, who was transferred to our emergency department with progressively severe headache and jaw pain for one-week. Read More

J Neurosurg Spine 2018 Nov 1:1-5. Epub 2018 Nov 1.

1Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Ontario, Canada; and.

The pathogenesis of thoracic ventral intradural spinal arachnoid cyst (ISAC) is unknown due to its extremely low incidence. In addition, its surgical treatment is complicated because of the ventral location, large craniocaudal extension, and frequent coexistence of syringomyelia. The optimal surgical strategy for thoracic ventral ISAC remains unclear and continues to be a matter of debate. Read More

Urol Int 2018 Nov 28:1-5. Epub 2018 Nov 28.

Department of Obstetrics and Gynecology, Division of Urogynecology, Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey.

Sacrocolpopexy is the gold standard treatment for apical compartment prolapse with reported success rates of 78-100%. Spondylodiscitis is a rare complication of sacrocolpopexy and includes a spectrum of spinal infections such as discitis, osteomyelitis, epidural abscess, meningitis, subdural empyema, and spinal cord abscess. Here we report a case of spondylodiscitis following laparoscopic sacrocolpopexy with long-term follow-up and discuss management of spondylodiscitis after abdominal sacrocolpopexy, with a review of the literature. Read More

World Neurosurg 2019 Feb 24;122:590-592. Epub 2018 Nov 24.

Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.

Background: Rapid progression of metastatic non-small cell lung cancer (NSCLC) after discontinuation of tyrosine kinase inhibitors or anaplastic lymphoma kinase (ALK) inhibitors has been described and is associated with a poor prognosis. We describe the first reported case of accelerated NSCLC tumor extension throughout the entire spinal epidural space.

Case Description: A 68-year-old woman with stage IV ALK-positive metastatic NSCLC presented with acute neck pain, urinary retention, and lower extremity weakness 15 days post discontinuation of alectinib. Read More

Asian J Neurosurg 2018 Oct-Dec;13(4):1247-1249

Faculty of Medicine, Aleppo University Hospital, University of Aleppo, Aleppo, Syria.

Abdominal presentations in patients with spinal-epidural abscess (SEA) are not uncommon. However, it needs to be continually emphasized that the atypical presentations of these diseases could delay the timely diagnosis and consequently prompt management, which threatens spinal cord, leading to potential to paralysis or even death. We report a case of a young girl who presented with abdominal pain and fever. Read More

Clin Spine Surg 2018 Nov 16. Epub 2018 Nov 16.

Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA.

Study Design: This was a retrospective case-control study.

Objective: We aim to describe a novel 5-point grading system to determine the degree and severity of spinal cord compression secondary to a spinal epidural abscess (SEA). Secondarily, we aim to correlate the degree of compression with clinical presentation and outcomes. Read More

Intern Med 2018 Nov 19. Epub 2018 Nov 19.

Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Japan.

A 53-year-old Japanese man experienced fever/neck pain, and neck magnetic resonance imaging revealed a spinal epidural abscess. The following day, he developed a palpable mass with evident inflammatory signs in the right sternoclavicular joint (SCJ) with severe pain. Ultrasound revealed synovitis with remarkable power Doppler signals in the right SCJ. Read More

Transpl Infect Dis 2019 Feb 27;21(1):e13025. Epub 2018 Nov 27.

Institute of Human Virology and Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland.

Nocardia species represent a well-recognized yet uncommon cause of opportunistic infections in humans. It most frequently presents as a pulmonary infection with or without central nervous system involvement. It is a very rare cause of spinal abscesses, with only 26 cases reported in the literature. Read More

J Investig Med High Impact Case Rep 2018 Jan-Dec;6:2324709618807504. Epub 2018 Oct 28.

State University of New York Upstate Medical University, Syracuse, NY, USA.

In this article, we report the case of a 75-year-old man who was presented with new low back pain for 2 weeks. His past history was significant for severe aortic stenosis necessitating bioprosthetic aortic valve placement 4 years ago, hypertension, and coronary artery disease. His physical examination was positive for point tenderness over the lower lumbar spine. Read More

Orthop Rev (Pavia) 2018 Sep 26;10(3):7693. Epub 2018 Sep 26.

Department of Orthopaedics, Division of Spine Surgery, Alpert Medical School of Brown University, Providence, RI, USA.

Spinal epidural abscesses (SEA) can be challenging to diagnose and may result in serious adverse outcomes sometimes leading to neurologic compromise, sepsis, and even death. While SEA may lead to litigation for healthcare providers, little is known about the medicolegal factors predicting case outcome of SEA related litigation cases. Three large medicolegal databases (VerdictSearch, Westlaw, and LexisNexis) were queried for SEA-related malpractice cases. Read More

Int J Pediatr Otorhinolaryngol 2018 Dec 18;115:45-48. Epub 2018 Sep 18.

Department of ENT and Head and Neck Surgery, University Hospital Gui de Chauliac, 80 Avenue Augustin Fliche, 34295, Montpellier Cedex 5, University of Montpellier, France. Electronic address:

Intracranial empyema is a rare but serious complication of sinusitis in children. Myelodysplastic/myeloproliferative syndromes (MMS), including juvenile myelomonocytic leukemia (JMML), can lead to immunosuppression, thus favouring infections. We report the case of a sphenoid sinogenic retro-clival extradural empyema in a 14-year-old female patient associated with JMML. Read More

J Assoc Physicians India 2018 Apr;66(4):72-74

Senior Resident Neurosurgery, N.S.C.B. Medical College, Jabalpur, Madhya Pradesh.

Tuberculosis of the central nervous system (CNS) is well known. CNS involvement can occur in the form of tubercular meningitis (TBM), tuberculous vasculitis, tuberculoma and rarely brain abscess. Tubercular granulomas generally solitary and occur in the brain but they may be multiple and involve other areas such as spinal cord, epidural space and subdural space also. Read More

Case Rep Orthop 2018 20;2018:1091932. Epub 2018 Sep 20.

Rockford Pain Center, Rockford, USA.

Salmonella vertebral discitis/osteomyelitis is a rare manifestation of Salmonella infection. Here, we report a case of a 54-year-old Caucasian male who presented with five weeks of progressively worsening bilateral low back, buttock, and lower extremity pain following an 8-foot fall onto concrete from a ladder. Initial workup following the fall included hip X-ray and MRI of the lumbar spine and revealed only mild lumbar facet arthropathy and moderate left neural foraminal stenosis at L3-L4 without any concomitant hip or spine fracture. Read More

Emerg Med Clin North Am 2018 Nov 6;36(4):751-766. Epub 2018 Sep 6.

Division of Emergency Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8072, St Louis, MO 63110, USA; Division of Infectious Diseases, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8051, St Louis, MO 63110, USA. Electronic address:

Bone and joint infections are potentially limb-threatening or even life-threatening diseases. Emergency physicians must consider infection when evaluating musculoskeletal complaints, as misdiagnosis can have significant consequences. Patients with bone and joint infections can have heterogeneous presentations with nonspecific signs and symptoms. Read More

Am J Med 2018 Oct 3. Epub 2018 Oct 3.

Division of Spine Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI.

Atraumatic spinal emergencies often present a diagnostic and management dilemma for health care practitioners. Spinal epidural abscess, cauda equina syndrome, and spinal epidural hematoma are conditions that can insidiously present to outpatient medical offices, urgent care centers, and emergency departments. Unless a high level of clinical suspicion is maintained, these clinical entities may be initially misdiagnosed and mismanaged. Read More