intramedullary spinal cord tubercular abscess are very rare . the first description in 1830 by hart , only about 100 cases of intramedullary abscess have been reported . this condition is very rare in children , and it is important to remember this entity , if detected and treated early , has a favorable prognosis . a 4-month - old female baby presented to us with history of intermittent fever since 2 months ; lethargy , weak cry , refusal of feeds since 1-week ; acute onset weakness of both lower limbs since 3 days . the fever was intermittent for which she had been hospitalized twice with no relief of fever even after having received several antibiotics . the mother had also noticed that the baby cried excessively during micturition . according to the mother , at birth there was a small midline swelling over the sacral region with discoloration of overlying skin and a sinus with tuft of hair , but no discharge . ultrasonography of the spine at 2 days of birth showed spina bifida at l4 level . on examination , she was afebrile , pale , and irritable , with flaccid paraplegia and a midline sacral dimple with dermal sinus . the magnetic resonance ( mr ) scan of the brain was normal while that of the spine showed an intramedullary high signal on t2-weighted images with poorly defined marginal enhancement on t1-weighted images extending from d11 to s3 level and a low lying conus with tethered filum terminale . on sagittal sections , a subcutaneous tract in lower back at s2 level extending from the skin up to sacral canal was noted . also noted was an over distended bladder [ figure 1 ] . t2 sagittal section with contrast showing well defined abscess cavity with a full bladder an l2l4 laminectomy was done . the abscess was drained ; biopsy of the granulation tissue was taken and sent for examination . it was found that the dermal sinus was communicating with lower end of the dural tube , which was excised and sent for examination . the pus stained positive for acid - fast bacilli ( ziehl neelsen stain ) while the gram stain was negative [ figure 2 ] . on histopathology , the wall of the abscess composed of necrotizing granulomatous inflammation , suggestive of tuberculous infection ; while the dermal sinus examination revealed chronic inflammation and fibrosis . the baby responded well to anti - tubercular treatment . a retrospective search for finding out the source of infection proved unsuccessful . gurin ( bcg ) vaccination at birth , with no other focus of tubercular infection elsewhere in the body . the mother with all family members , including the servants were screened for tuberculosis with chest x - ray and three serial early morning sputum examinations , but none tested positive . simon et al . in a review of intramedullary spinal cord abscess in children found slight male predominance ( 55% ) with median age of 36 months ( range : 18 days to 7 years ) , while our patient was a 4-month - old female infant . staphylococcus and streptococcus were the most commonly isolated organisms in 100 cases of intramedullary pyogenic abscesses reported by desai et al . intramedullary spinal cord tuberculoma due to mtb infection tends to occur predominantly in young people of developing countries and are associated with systemic diseases , usually pulmonary . furthermore , there were no skin lesions over the back , which ruled out the possibility of cutaneous tubercular infection . in children , hematogenous spread from a variety of sources does occur , but preexisting congenital defects in spinal cord development are a more common means by which infection occurs . the dermal sinus has been increasingly observed as a source of intramedullary spinal abscess in the antibiotic era , likely because other deep seated and adjacent infections are more effectively eliminated before they spread to the spinal cord . staphylococcus aureus was reported to be the commonest offending organism in the case of abscess associated with dermal sinus in a recent series . in our patient our patient had a dermal sinus in - communication with the dural tube and an intramedullary abscess , which was found to be tubercular , though no hypothesis or explanation of the pathophysiology could be stated . prompt surgical drainage of abscess with appropriate antibiotics and anti - tubercular treatment is recommended . our patient made a good recovery after drainage of the abscess and anti - tubercular treatment . the patient had only received bcg vaccination at birth , and while the source of this tubercular abscess formation could not be identified , the possibility of vaccination associated tubercular infection could not be ruled out . at 3 years she has undergone orthopedic corrective surgery for the left foot deformity and requires clean intermittent catheterization as management of her neurogenic bladder .
spinal intramedullary tubercular abscess itself is a rare entity . 
 very few cases have been reported . 
 we report a case of a 4-month - old female with a dermal sinus in lower back since birth , intermittent fever for 2 months , acute onset paraparesis and bowel bladder involvement showing an intramedullary contrast enhancing lesion extending from d11 to s2 level with low lying conus , and a subcutaneous tract in lower back at s2 level extending from skin up to the sacral canal on magnetic resonance imaging of the spine . 
 drainage of abscess and biopsy revealed tubercular infection on histopathology . 
 the patient made a good recovery with anti - tubercular treatment and physiotherapy . 
 the source of tubercular infection could not be established . 
 the baby had received bacillus calmette 
 gurin vaccination at birth and the possibility of vaccination associated tubercular infection could not be ruled out .