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| LETTER TO EDITOR |
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| Year : 2012 | Volume
: 60
| Issue : 2 | Page : 236-237 |
Tuberculous spinal subdural abscess in an infant with dermal sinus
Dhaval Shukla, Jagathlal Gangadharan, Bhagvatula Indira Devi, Sudhir Ambekar
Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| Date of Submission | 20-Jan-2012 |
| Date of Decision | 22-Jan-2012 |
| Date of Acceptance | 11-Mar-2012 |
| Date of Web Publication | 19-May-2012 |
Correspondence Address:
Dhaval Shukla
Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.96420
How to cite this article:
Shukla D, Gangadharan J, Devi BI, Ambekar S. Tuberculous spinal subdural abscess in an infant with dermal sinus. Neurol India 2012;60:236-7 |
Sir,
Tuberculosis of the central nervous system (CNS) is most severe and life threatening in children. [1] Various forms of spinal tuberculosis include spinal arachnoiditis with radiculomyelopathy, spinal tuberculoma, epidural granuloma, discitis, and spondylitis. [2] Tuberculous spinal subdural abscess (SSA) is very rare and till date only four cases have been reported [Table 1]. [3],[4],[5],[6] We report a case of tuberculous SSA in an infant with dermal sinus.
An 8-month-old infant presented to us with fever since 5 months, lethargy, weak cry, and refusal of feeds since 1 week, and acute onset of weakness of both lower limbs since 3 days. He also had a sinus opening in the lower back since birth with seropurulent discharge for the last 3 days. Examination revealed flaccid paraplegia and midline sacral sinus. Magnetic resonance imaging (MRI) of spine [Figure 1]a revealed multiple intradural fluid loculations from D2 to sacrum, with contrast enhancement of the dura and septae. The sinus tract was seen continuous with intradural space at L5-S1 level [Figure 1]b. Clinico-radiological diagnosis was infected dermal sinus with SSA. L4 to S2 laminotomy and excision of infected dermoid, and drainage of SSA was done. The operative findings were dermal sinus extending from skin over S2 to L5-S1 level and communicating with intradural dermoid. The dermoid was excised, subdural abscess drained, and thorough irrigation of subdural space was done. A subdural drain was left for 7 days. Smear examination of pus showed acid fast bacilli (AFB). Culture of pus yielded Escherichia More Details coli sensitive to meropenem. Histopathologic examination of the tissue showed an infected dermoid and dermal sinus tract with florid granulation tissue [Figure 2]. The inflammatory infiltrates within the wall of the sinus comprised mainly lymphoplasmacytic cells. Ziehl-Neelsen stain showed several AFB. Within 1 week of surgery, the child showed signs of improvement. He received meropenem for 4 weeks and was discharged on antitubercular drug therapy. At 8 months of follow-up, he was able to walk without support. MRI of spine showed complete resolution of abscess [Figure 1]c.  | Figure 1: (a) MRI of spine sagittal T1W post-contrast images showing multiple enhancing loculations with spinal subdural space from T2 to S2 level. (b) MRI of spine sagittal T2W images showing a dermal sinus at L5-S1. (c) MRI of thoracolumbar spine sagittal T1W post-contrast images, done at follow-up, showing complete resolution of abscess
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 | Figure 2: Microphotographs show dermoid cyst (a) with florid infiltration by polymorphonuclear leukocytes (b) (original magnification ×160). Inset in B shows AFB positive tubercle bacilli (×800)
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SSA is a rare condition and only 61 cases have been reported so far. [7] It is most commonly seen in elderly females. The commonest cause is hematogenous spread and Staphylococcus aureus  is isolated in about 46% of patients. [7] The other modes of spread are direct extension of a contiguous infection, iatrogenic causes, and dermal sinus. [7] In patients with dermal sinus and dermoid cyst, meningitis is more common. However, dermal sinus infrequently leads to spinal subdural abscess. The causative organisms are Staphylococcus, Streptococcus, E. coli, Actinomyces, Pneumococcus, and Proteus. [8] Tuberculous involvement of the subdural space may occur by hematogenous spread, iatrogenic route, or by extension from an adjacent abscess. Tuberculous SSA is described in immunocompromised patients [5] and in patients with preexisting tuberculosis elsewhere in body. [4] Our patient is immunocompetent without any demonstrable focus of tuberculosis elsewhere in the body. He probably had tuberculosis as suggested by the constituent symptoms before neurological deterioration. The acute presentation was due to superimposed pyogenic infection from dermal sinus. This probably explains dual infection of the subdural space with Mycobacterium tuberculosis and E. coli. Surgical evacuation, excision of dermal sinus, and dermoid followed by appropriate antibiotic therapy targeting both the organisms led to complete recovery in our case. Any patient with dermal sinus presenting with lower limb weakness should be investigated for intraspinal infection. Surgery should be considered to procure material for histopathologic and microbiological investigation, and evacuation of abscess. The mainstay of treatment for tuberculous SSA is antitubercular therapy. With early surgery and appropriate medical treatment, the outcome of tuberculous SSA is favorable.
| » Acknowledgments | |  |
We would like to acknowledge Dr. Vani Santosh, Professor and Head, Department of Neuropathology, NIMHANS, Bangalore, for helping us in diagnosing the case and providing the histopathology photographs. We also thank Dr. S. Nagarathna, Associate Professor in Neuromicrobiology for her inputs during the diagnosis.
| » References | | |
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| 2. | du Plessis J, Andronikou S, Theron S, Wieselthaler N, Hayes M. Unusual forms of spinal tuberculosis. Childs Nerv Syst 2008;24:453-7.
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| 8. | Park SW, Yoon SH, Cho KH, Shin YS, Ahn YH. Infantile lumbosacral spinal subdural abscess with sacral dermal sinus tract. Spine 2007;32:E52-5.
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[Figure 1], [Figure 2]
[Table 1]
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