Unusual co-presentation of cervical lordosis reversal and bilateral psoas abscess in a paediatric patient with spinal tuberculosis

INTRODUCTION

Cervical lordosis refers to the normal inward curvature of the neck region of the spine, which is essential for maintaining head balance, posture, and overall spinal alignment. Pott’s disease, also known as spinal tuberculosis (TB), is caused by Mycobacterium tuberculosis and can result in vertebral damage, pain, and neurological symptoms.^[2,6] Psoas abscess is an uncommon but serious complication, often arising from infection by Staphylococcus aureus or spreading from nearby sources such as spinal infections.^[5] Pulmonary TB continues to pose a major global health challenge due to its high incidence and infectious potential.^[1,3] Although each of these conditions may occur separately, their simultaneous presentation is rare yet clinically important. Spinal TB can sometimes progress to form a cold abscess, which may track along fascial planes into the psoas muscle, resulting in abscess formation.^[6,7] Approximately 50% of skeletal TB cases involve the spine, and skeletal TB represents 10–35% of extra-pulmonary TB cases.^[6] Psoas abscesses are estimated to affect 0.4/100,000 individuals, though the actual prevalence may be underestimated due to a lack of routine testing in patients without symptoms.^[5] According to the WHO Global TB Report 2022, around 10.6 million new TB cases were reported worldwide in 2021, reinforcing the continued public health burden of TB.^[1] The END TB strategy aims to reduce global TB deaths by 95% and incidence by 90% by 2035.^[4] Disruptions in spinal curvature, such as cervical lordosis reversal, can lead to chronic functional impairments if not addressed promptly. As per the ICMR guidelines, early detection using MRI and immediate initiation of anti-tubercular therapy (ATT) are essential to prevent long-term deformities and complications.^[8] The simultaneous presence of pulmonary TB, spinal involvement, and paraspinal abscesses remains uncommon due to the generally localised behaviour of TB. However, delays in diagnosis and treatment can lead to such severe outcomes, highlighting the critical importance of early clinical recognition and integrated care.

TB remains a major global health concern, particularly in low- and middle-income countries, where socioeconomic and nutritional challenges contribute to its persistence.^[1] First described by Pott in 1779, spinal involvement continues to represent one of the most severe forms of extra-pulmonary TB.^[2] Although the disease predominantly affects the lungs, haematogenous or lymphatic spread can lead to multisystem involvement, especially in children with vulnerable immune responses.^[3,4]

Pulmonary TB serves as the primary source of transmission and may present with subtle or atypical features in paediatric patients, often contributing to diagnostic delays.^[3,8] Such delays increase the likelihood of dissemination to extra-pulmonary sites, including the spine, psoas muscle, and paraspinal tissues.^[7]

Spinal TB (Pott’s disease) results from haematogenous seeding of the vertebrae and is characterised by vertebral destruction, disc space narrowing, and potential neurological compromise.^[6,9] Paediatric spinal TB tends to be more aggressive due to skeletal immaturity and a higher risk of deformity if diagnosis and treatment are delayed.^[8]

The concurrent presence of pulmonary TB, spinal TB, bilateral psoas abscesses, and cervical alignment abnormalities is extremely uncommon in children and reflects advanced disease.^[5,10] Early recognition with MRI and prompt initiation of ATT are essential to prevent long-term disability.^[11-13] This case highlights a rare and severe multisite TB presentation in a 16-year-old female, emphasising the importance of timely diagnosis and coordinated multidisciplinary care.^[14-17]

CASE REPORT

A 16-year-old female patient from a lower-middle-class background was admitted to the paediatric ward with chief complaints of inability to stand upright due to bilateral lower limb weakness for 20 days, back pain for 1 month, and cough for 6 months. She experienced severe back pain aggravated by movement, accompanied by reduced appetite and fatigue. There was no known family history of TB, though her father had a chronic cough suggestive of possible exposure. Nutritional assessment indicated mild undernutrition, and vaccination history was complete per the National Immunization Schedule. Laboratory investigation results are shown in Table 1.

Figure 1 demonstrates a chest X-ray (posteroanterior view) revealing bilateral patchy, linear, and nodular opacities with areas of breakdown, consistent with active pulmonary tuberculosis. Figure 2a depicts a sagittal MRI demonstrating sacralisation of L5, straightening of the lumbar spine, and destructive changes at L2–L3 with endplate erosion and disc space narrowing suggestive of Pott’s disease. Figure 2b depicts axial MRI illustrating bilateral psoas abscesses with associated epidural collection, consistent with advanced spondylodiscitis due to spinal TB. Whole-spine screening additionally demonstrated loss of cervical lordosis (reversal of the normal cervical curvature) and disc protrusions at C3–C6. High-resolution computed tomography (HRCT) chest demonstrated active pulmonary TB, and a positive Mantoux test (12 mm induration) confirmed prior TB exposure. Abdominal ultrasound revealed hepatomegaly and gall bladder sludge.

Close

Figure 1:

Chest X-ray (posteroanterior view) showing bilateral patchy opacities in the lung fields. The circled area highlights parenchymal breakdown, suggestive of active pulmonary tuberculosis.

Export to PPT

Close

Figure 2:

(a) MRI lumbosacral spine (sagittal view). (b) MRI showing bilateral psoas abscess (axial view).

Export to PPT

The patient was diagnosed with Pott’s spine, pulmonary TB, bilateral psoas abscess, and cervical lordosis. During hospitalisation, she developed severe bradycardia, with pulse rate dropping below 30 beats/min, necessitating ICU admission. The anti-tubercular regimen is shown in Table 2, comprising a fixed-dose combination of isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE) along with pyridoxine to prevent drug-induced neuropathy.

Other medications administered during hospitalisation included ceftriaxone, diclofenac, paracetamol, ibuprofen, prednisolone, tolperisone, alprazolam, calcium, Vitamin D3, labetalol, nifedipine, amlodipine, prazosin, potassium chloride, zinc, lactulose, topical emollient, ipratropium bromide, salbutamol, and an antitussive syrup. At discharge, the patient was prescribed paracetamol, pyridoxine, pantoprazole, linezolid, and continuation of the anti-tubercular regimen (HRZE) with becosules. She was discharged in a stable condition with partial neurological recovery and advised for regular follow-up. At the 3-month follow-up, the patient showed significant improvement in back pain and gait, with partial resolution of psoas abscesses on ultrasound. By 6 months, she regained near-normal mobility, no neurological deficits were observed, and inflammatory markers normalised. Repeat MRI demonstrated reduced vertebral inflammation and near-complete abscess resolution, confirming effective therapeutic response.

DISCUSSION

This case highlights a rare and severe presentation of spinal TB in a 16-year-old female, involving Pott’s spine, bilateral psoas abscesses, pulmonary TB and loss of cervical lordosis (reversal of normal curvature). Although spinal TB typically affects the thoracolumbar region, the concurrent presence of cervical alignment abnormality and psoas abscesses in a paediatric patient is highly unusual. Psoas abscess occurs in only 3–5% of spinal TB cases and even less frequently in children, making this constellation particularly noteworthy.^[9,10] Compared with previously described cases, our patient demonstrated a more aggressive pattern of dissemination. Gupta et al.^[8] reported a paediatric Pott’s spine without cervical involvement, while de Souza et al.^[13] described a psoas abscess in an adult patient requiring surgical drainage. In contrast, this case involved extensive L2 – L3 destruction, bilateral abscesses, pulmonary disease, and cervical alignment changes, indicating more widespread spinal involvement and a delayed diagnosis. The loss of cervical lordosis in this patient was most likely due to pain-induced paraspinal muscle spasm and inflammatory irritation, a reversible protective mechanism rather than a fixed structural deformity. Prior studies report that cervical alignment abnormalities in spinal infections often normalise as inflammation subsides and physiotherapy begins.^[14,15] Loss of cervical lordosis in spinal TB is a recognised sign of paraspinal spasm and inflammation,^[14] and its presence should prompt careful evaluation of the entire spine to exclude additional sites of involvement. Another striking feature in this case was profound bradycardia, with heart rates dropping below 30 beats/min. Although rare, bradycardia in spinal TB may reflect autonomic dysregulation due to epidural extension of inflammation affecting sympathetic pathways, and may be exacerbated by antihypertensive medications such as labetalol. Improvement in heart rate following adjustment of therapy and reduction of inflammation supports this explanation. Socioeconomic factors significantly contributed to diagnostic delay. Limited financial resources and late access to advanced imaging allowed disease progression to multisite involvement, consistent with evidence that malnutrition and delayed care worsen TB severity in children.^[16] Follow-up at 3 and 6 months demonstrated symptomatic improvement, reduction in inflammatory markers, and partial radiological resolution of psoas abscesses, highlighting the effectiveness of early, sustained ATT. This case reinforces the need for early MRI evaluation in paediatric patients presenting with persistent back pain or mobility limitation to prevent irreversible neurological deficits.^[17]

CONCLUSION

These cases emphasise the importance of early recognition of multisystem involvement in paediatric TB, particularly when rare combinations such as vertebral destruction, bilateral psoas abscesses, pulmonary involvement, and loss of cervical lordosis occur. As loss of cervical lordosis represents a pain-related inflammatory response, its detection should prompt evaluation of the entire spine to rule out additional pathology. Early imaging, timely ATT, and coordinated multidisciplinary management are essential to prevent neurological compromise and long-term deformity in children with advanced spinal TB.