Acute flaccid paralysis in young children: “Watch their back”

Abstract

Background : Congenital dermal sinus is a developmental malformation which may be associated with sinus tract between the skin and the deeper tissues even spinal cord. Hence, can have complicated presentations like gait abnormalities, infections, urinary symptoms or mass lesions. We hereby describe a case series of six children with spinal abscesses complicating dermal sinus. Methods : All children with flaccid paralysis presented to our center during the period January 2016 to May 2017 were reviewed. The children were evaluated by Spinal imaging, Nerve conduction studies, and cerebrospinal fluid analysis or biochemical and microbiology investigations as indicated. The clinical symptoms, neurodeficits, radiological findings, culture of Cerebrospinal fluid or blood and treatment provided were analyzed. These children were followed up clinically for assessment of neurodeficits. Results : Of a total of 111 children of acute flaccid paralysis admitted during this period, six children had spinal abscess associated with dermal sinus. (The other diagnosis were Guillain Barre syndrome, myositis, myelitis). The median age of diagnosis and median duration of symptoms was 8.5 months and 33 days. All six children presented with progressive weakness of lower limbs; fever and urinary symptoms were present in only two children. In none of the children was spinal cord infection kept as an initial differential diagnosis. All children had evidence of intra-medullary abscess, cord edema and spinal archanoiditis. One child had holocord involvement, while rest had involvement of dorso-lumbosacral spine involvement. Two children had epidural abscess while one child had paravertebral abscess. Four children needed spinal laminotomy. The offending organism was isolated in two children (E.coli). All except one (parents declined treatment) were treated with intravenous antibiotics for 6-8 weeks. All children had motor improvement after treatment but all were left with severe deficits and residual neurogenic bladder Conclusion : The infection of the spinal cord and meninges due to a dermal sinus is rare cause of paralysis and can present without fever. In any child with flaccid paralysis, a careful examination of back for dermal sinus is critical to suspect this diagnosis.