Intramedullary abscess complicating congenital dermal sinus tract in an infant: A rare occurrence

Abstract

Case reportA four month old baby girl was brought to our department with a history of progressive decrease in movements of the left lower limb of three weeks duration and right lower limb of one day duration. The baby was intermittently febrile since three days prior to hospital admission and also had retention of urine of one day duration. The baby did not have any seizures, altered sensorium, vomiting or any history suggestive of central nervous system (CNS) involvement or raised intracranial tension. Parents noticed decreased sensations in lower limbs. The mother also reported that when pinched on the left leg she was not wincing or crying. She had a birth mark with a dimple in the lower back from which a recurrent discharge of white fluid was present since one and a half months of age. The parents had consulted multiple doctors including a neurosurgeon for the same but was reassured and sent back.On examination at the time of admission, the baby was conscious and alert, but irritable. The cranial nerves and upper limbs were normal. She had dorsolumbar scoliosis with convexity to the left, lax anterior abdominal wall on the left side and flaccid anal sphincter. There was a pale pink patch (3×3cm) with a central dimple in the lumbosacral area, approximately 3.5cm above the gluteal cleft suggestive of a congenital dermal sinus with neuro-_________________________________________ The authors declare that there are no conflicts of interest Personal funding was used for the project. Open Access Article published under the CreativeCommons Attribution CC-BY License.cutaneous marker (Figure 1). Her lower limbs were hypotonic with complete paralysis (power 0/5). Bilateral knee jerks, ankle jerks and plantar responses were absent. There was no response to pain in the lower extremities. Laboratory investigations showed leucocytosis with neutrophilia (White blood cell count 23,000/µL with 60% neutrophils) and elevated C-reactive protein (22.5 mg/L; normal <5 mg/L). X-ray of lumbosacral spine showed dorsolumbar scoliosis. Magnetic resonance imaging (MRI) of spine showed absent posterior elements at S1 and S2 with tethered cord and enlarged conus. There was an intramedullary abscess extending from D3 to S2 with a sinus tract extending to the skin from the thecal sac attached to the conus (Figure 2).She underwent L3 to S2 laminoplasty with excision of the dermal sinus. The intramedullary abscess was evacuated and the tethered cord released (Figure 3). An epidermoid tumour associated with the CDS noticed intraoperatively was also excised (Figure 4).