SPINE Volume 32, Number 23, pp E678 –E681 ©2007, Lippincott Williams & Wilkins, Inc. An Unusual Case of Craniovertebral Junction Tuberculosis in an Infant Sudhir K. Kapoor, MS, Akshay Tiwari, MS, and Aashish Chaudhry, MBBS Study Design. We present, to the best of our knowl- edge, the first reported case of craniovertebral junction tuberculosis with complete quadriplegia in an infant. Objective. To describe report of an unusual case and discuss the difficulties and peculiarities of diagnosis, management, and follow-up of craniovertebral tuberculo- sis in an infant. Summary of Background Data. Spinal tuberculosis is prevalent in areas where tuberculosis is endemic, and its incidence is on the rise in developed nations with the rising incidence of HIV/AIDS. Although common in chil- dren and young adults, spinal tuberculosis is rare in in- fants. Again, craniovertebral tuberculosis is one of the rarest forms of spinal tuberculosis. Methods. The infant presented to us at the age of 9 months with Grade IV quadriplegia. Among many of the clinical differential diagnoses, craniovertebral tuberculo- sis was suspected only on MRI and proved after fine needle aspiration cytology demonstrated granulomas. The patient was subjected to transoral debridement, im- mobilized with help of a pair of pillows by either side of the head and multidrug antitubercular treatment was started, which continued for duration of 12 months. Results. At the last follow-up of 1 year, the patient had recovered fully and caught up with the milestones suit- able for her age. Conclusion. Craniovertebral tuberculosis is difficult to diagnose and treat in infants. A high index of suspicion is essential for a prompt diagnosis and treatment, which is all the more crucial in this age group. Key words: complete quadriplegia, infant, craniover- tebral tuberculosis. Spine 2007;32:E678 –E681 Skeletal tuberculosis, apart from being endemic in devel- oping countries, has posed resurgence in the developed world as well, with HIV/AIDS preparing the background for the comeback. 1 Spinal tuberculosis is the commonest form of osteoarticular tuberculosis, accounting for al- most 50% of the cases. 2 While it is a disease of children and young adults, spinal tuberculosis is unusual in an infant. 3 We present the first case of craniovertebral tu- berculosis with complete quadriplegia in an infant re- ported in the English literature. Case Report A 9-month-old female child reported to the pediatrics department of our hospital with the complaints of com- plete cessation of all movements in all the 4 limbs, for a period of 15 days. The mother complained that the child was not able to sit or even hold her head for this dura- tion. The developmental history revealed that she had attained all the milestones at the expected rate. The birth of the child was uneventful, although the delivery was not institutional but home based. The siblings of the child had no similar complaints. The child was fully vac- cinated, including BCG vaccine. On examination, the child appeared comfortable, with a respiratory rate of 22 per minute and a heart rate of 100 per minute. The child was normal as far as visual, auditory, and vocal functions are concerned. There was no movement in both the upper and lower limbs: neither spontaneous nor in response to a stimulus. Both the knee jerks and ankle jerks were brisk, and the plantar response was extensor on either side. A gentle attempt at rotatory movement of the cervical spine provoked the child to cry, indicating a painful condition of the cervical spine. The hemogram of the child revealed a normal profile, but an erythrocyte sedimentation rate of 55 mm in the first hour. Mantoux test was positive with 15 mm indu- ration. Radiographs of the cervical spine, including open mouth views, revealed no bony or soft tissue abnormal- ity. An MRI of the craniovertebral region was obtained, which revealed areas of destruction in the atlas, occiput, and axis. Pus and granulation tissue were also evident in the prevertebral, paravertebral, and intraspinal regions (Figure 1). The spinal cord at the level of first and second cervical vertebrae showed increased signal intensity sug- gesting edema of the cord. The radiologist’s impression was an infective pathology of the craniovertebral junc- tion, possibly tuberculosis. Considering the extremely young age of presentation, it was considered prudent to obtain a microbiological and/or a histologic diagnosis of the pathology before accepting the diagnosis of tuberculosis of the spine. The patient was taken up for fine needle aspiration under general anesthesia and fluoroscopic guidance (Figure 2). The aspirate failed to show acid-fast bacilli, but showed histopathology consisting of tubercles with central case- ation, highly suggestive of tuberculous pathology. The parents were screened for tuberculosis, including de- tailed history, examination, a chest radiograph, and an ultrasound of the abdomen, all of which were normal. ELISA for HIV were nonreactive in the child as well as the parents. From the Lady Hardinge Medical College and Associated Hospitals, New Delhi, India. Acknowledgment date: October 10, 2006. First revision date: Decem- ber 15, 2006. Acceptance date: March 6, 2007. The manuscript submitted does not contain information about medical device(s)/drug(s). No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Sudhir K. Kapoor, MS, C-610, Saraswati Vihar, Pitampura, New Delhi 110034, India; E-mail: sumasudhir2003@yahoo.co.in, akshay_t_2000@yahoo.com E678