Holocord abscess in association with congenital dermal sinus
An 18-month-old girl child presented with rapidly progressive bilateral lower limb weakness with fever for 2 months. The mother of the child also noticed that she was not feeling any sensation below the nipples and had bladder incontinence. The fever was intermittent and the child was on several antibiotics without any benefit. Neurological examination showed conscious and active child. She had flaccid paraplegia with grade “0” power with absent deep tendon reflexes. Sensory examination showed absent sensation to pain below D4 level on both sides. Power, tone, and sensation were normal in the upper limbs. There were no signs of meningeal irritation. Careful examination of the back showed a very small dermal sinus in the lower lumbar region, discharging pus on digital pressure. Magnetic resonance imaging (MRI) showed multiple coalescing ring enhancing lesions in the spinal cord extending from D4 to L5 with cord edema upto cervical level []. The differential diagnosis considered were holocord glioma and holocord abscess. Modified osteoplastic laminotomy, described by Raimondi et al.,[] was performed from D4 to L5 []. The dermal sinus tract was seen to extend from the skin at L5 and end intradurally at the same level. Dura was opened and there was dermoid material and pus in the lumbar region The spinal cord was found to be diffusely enlarged. Myelotomy was performed at different levels and pus was evacuated from the spinal cord []. There were extensive arachnoidal adhesions. In view of the extensive nature of the abscess, no attempt was made to excise the abscess capsule. The dura was closed with fascial graft. The laminotomy flap was replaced []. The child stood the surgery well and the postoperative period was uneventful. Escherichia coli and Pseudomonas aeruginosa were grown on culture. She was started on antibiotics as per the sensitivity report. She started showing some neurological improvement within a few days in the form of some movement in both the legs. She was on long-term antibiotics for 8 weeks and physiotherapy. At 2 months follow-up, she had grade 3 power in the right lower limb and grade 1-2 power in the left. Sensory level was at D12 both sides. Follow-up MRI shows good resolution of the intramedullary abscess [].