Introduction: We present a case of urosepsis with secondary infection of a right brachial plexus schwannoma, manifesting as intractable right arm pain. Infected schwannomas are exceptionally rare, with only four cases reported to date.
Methods: 51-year-old male with history of schwannomatosis presented with acute-on-chronic, burning right arm pain predominantly affecting the forearm and hand, accompanied by proximal right arm weakness of a right brachial plexus schwannoma, and resection was planned. Contrast-enhanced MRI showed stable cystic right brachial plexus schwannoma with degeneration of the tumor without malignant transformation. On the day of surgery, the patient developed altered mental status and hemodynamic instability, with Tmax 102.7°F, WBC 17.7, CRP 206.7, ESR 67, Procalcitonin 1.54 suggestive of sepsis. Blood cultures grew E. coli, and a prostatic abscess was identified on CT of the abdomen and pelvis. Surgery was cancelled and he was started on broad-spectrum antibiotics (vancomycin, ampicillin/sulbactam, tobramycin) and later narrowed to ceftriaxone. Despite treatment, the patient remained tachycardic and toxic-appearing. A CT chest with contrast ruled out pulmonary embolism but revealed fat stranding and lymphadenopathy around the right brachial plexus schwannoma, suggesting infection.
Results: A 5.9 x 4.8 x 2.5 cm nerve sheath tumor with intratumoral purulent material was sent to pathology, confirming the diagnosis of schwannoma with intralesional presence of E. coli. Given significant adhesions and inflammation surrounding the tumor, manipulation of the posterior cord was required. Postoperatively, the patient’s pain immediately resolved, and had transient weakness of the right shoulder, triceps, and wrist extension that resolved completely by postoperative day 3. His vital signs and WBC were normalized. He continued ceftriaxone treatment, later transitioned to oral cefpodoxime, and was discharged home on postoperative day 5.
Conclusion : Though rare, schwannoma infections pose a diagnostic challenge. Surgical resection, careful nerve preservation, and targeted antibiotic therapy are essential for optimal outcomes.
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