Delayed Diagnosis of Congenital Dermal Sinus Tract Presenting with Recurrent Meningitis and Paraplegia: Complete Neurological Recovery After Surgical and Targeted Therapy
This case report describes a 6-month-old infant with a delayed diagnosis of a congenital dermal sinus tract who suffered recurrent meningitis and paraplegia but achieved complete neurological recovery following surgical resection of an infected lumbosacral abscess and a 28-day course of targeted meropenem therapy.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Imagine your body's nervous system as a super-high-speed fiber-optic internet cable running from your brain down to your toes. Now, imagine that during the very early days of building a baby, a tiny, invisible tunnel accidentally gets left open between the outside world (the skin) and that delicate cable (the spinal cord). This is what doctors call a Congenital Dermal Sinus Tract (CDST). It's like a secret backdoor that shouldn't exist, lined with skin cells, stretching all the way from a tiny dimple on the baby's lower back down into the spinal canal.
In this story, we meet a 6-month-old baby boy who had this secret backdoor. For months, it was hiding in plain sight as a tiny, harmless-looking dimple on his sacrococcygeal region (the tailbone area). Most people might think, "Oh, just a little skin bump," but this dimple was actually a dangerous highway for germs.
The Breakdown: When the Backdoor Opens
Because this tunnel connected the outside skin directly to the fluid surrounding the spinal cord, bacteria could sneak in. About a month before the big crisis, the baby got sick with what looked like meningitis (an infection of the brain's protective lining) and was treated, but the root cause wasn't found. Then, the trouble came back with a vengeance. A mass the size of a walnut (growing from the size of a hazelnut) swelled up on his lower back, turning red and tender.
Worse, the infection spread inside. The baby became lethargic, his head fontanelle (the soft spot on top of the head) bulged, and he lost all movement in his legs. He was essentially paralyzed. It was a scary scene: a 6-month-12-day-old infant with a bulging head and legs that wouldn't move.
The Detective Work: MRI to the Rescue
Doctors needed to see inside without cutting anything open yet. They used a Magnetic Resonance Imaging (MRI) scan, which is like a super-powerful camera that can see through skin and bone. The scan revealed a massive cystic lesion (a fluid-filled sack) measuring 35 × 27 mm at the lumbosacral junction.
Think of this sack as a water balloon that had grown too big, squishing the spinal cord. The scan showed that the spinal cord was "tethered" (stuck in place like a kite string caught on a branch) and that the cord itself was expanding. The images also showed glowing edges around the nerves, which meant there was active inflammation and meningitis. The doctors realized this wasn't just a simple skin dimple; it was a complex spinal defect involving a meningomyelocele (where the spinal cord and its coverings poke out) and a tethered cord.
The Fix: Surgery and the Right Antibiotic
The team took the baby to the operating room. They performed a laminoplasty (a careful procedure to open up the spine) at levels L2–L4. Inside, they found a thick neural structure that looked more like a spinal cord than normal nerve fibers. They carefully removed the infected abscess tissue and the dangerous tunnel.
After surgery, the baby was put on antibiotics. At first, they used a broad-spectrum mix of vancomycin and meropenem. Then, they took a sample of the pus (the abscess) and grew the bacteria in a lab. The culprit was identified as Escherichia coli (E. coli). This makes sense because the tunnel was near the bottom of the body, where fecal bacteria live.
Once the lab confirmed that the E. coli was sensitive to meropenem but not necessarily needing vancomycin, they stopped the vancomycin and kept the baby on meropenem alone. They didn't stop after a few days; they kept the baby on this targeted therapy for a total of 28 days.
The Miracle: A Full Comeback
Here is the most amazing part of the story. When the baby arrived, he had paraplegia (paralysis of the lower body). But after the surgery and the full month of antibiotics, his muscle strength came back completely. He didn't just get a little better; he made a full neurological recovery.
One month later, a follow-up MRI showed everything looked normal. The inflammation was gone, the infection was cleared, and the baby was discharged in good condition.
What This Tells Us
This case is a big lesson for doctors and parents. It suggests that a tiny dimple on a baby's lower back shouldn't be ignored as just a "normal" skin mark. If a baby has recurrent meningitis (getting the brain infection more than once), especially with a sacral dimple, there might be a hidden tunnel connecting the skin to the spine.
The paper argues that if you wait too long, the infection can cause permanent paralysis. However, this story shows that even when the situation looks dire—with a paralyzed baby and a massive infection—prompt surgery combined with the right antibiotics can lead to a complete recovery. It's a reminder that catching these hidden tunnels early is the key to keeping the "fiber-optic cable" safe and sound.
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