A 22-year-old woman presented to our emergency department with a 9-week history of worsening neck stiffness, inability to grip objects, lift arms up, self-care and lower limb weakness. She reported no recent travel or history of trauma and denied previous TB exposure. Systemically, there had loss of appetite, weight loss and night sweats. On examination, Her neck was held in right lateral flexion with marked kyphosis. Neurological examination revealed upper limb hypertonia and power of 3/5 with lower limb hypotonia and 4/5 weakness. Reflexes were present and symmetrical and sensation to light touch was reduced in dermatomes below C5 with axillary sparing. Paraesthesia was noted in both arms and Lhermitte's sign was positive. No sphincteric dysfunction was noted. All base-line blood investigations were normal except ESR of 131 and a C-reactive protein of 94 IU. 

A lateral cervical spine radiograph demonstrated angulated kyphosis with partial destruction of C6 with soft tissue density in the pre-vertebral and retropharyngeal soft tissues. An MRI and CT scan of the cervical spine demonstrated altered signal intensity within the C5–C7 vertebral bodies with the complete destruction of the C6 vertebra with an epidural collection extending from the C3/4 disc space to the bottom of 1. There was no evidence of enhancement within the cord, but there was high signal intensity within it on T2 weighted scans; indicative of cord oedema.

Collectively, the appearances were consistent with an epidural abscess lying anterior to the cord in the cervical spine with large vertebral abscesses. A diagnosis of tuberculosis was made and the patient was commenced on quadruple anti-tubercular therapy (Rifampicin 450 mg o.d., Isoniazid 300 mg o.d., pyrazinamide 1.5 g o.d. and ethambutol 600 mg o.d.). Four days later the patient underwent anterior decompression of C5–C7 and corpectomy of C6 with an insertion of tricortical ilia cest Graft and plating and drainage of the pus collection at C3–C7. Tissue from the abscess was sent for pathological analysis, which grew Mycobacterium tuberculosis. Histopathology was consistent with Tuberculosis and organism was sensitive to first line ATT. The patient made an uneventful recovery and was mobilised with collar. The patient was given ATT for 9 months. There was a progressive improvement in neurology and blood parameters. MRI done at 9 months showed complete resolution of abscess and fusion of graft