Introduction: Intramedullary spinal cord abscess (ISCA) is an exceptionally rare yet potentially life threatening paediatric condition. Despite being a treatable cause of acute paraparesis or tetraparesis, diagnosis is often delayed owing to its rarity and nonspecific early clinical and radiological features, emphasising the importance of early recognition. Case presentation: We report a 2–year–5–month–old late preterm boy with failure to thrive who was referred with high grade fever and rapidly progressive left predominant flaccid tetraplegia, absent deep tendon reflexes, and preserved sensation and higher cortical functions. Inflammatory markers were markedly elevated. Cerebrospinal fluid analysisdemonstrated raised protein, hypoglycorrhachia, lymphocytic pleocytosis and sterile cultures. Screening for immunodeficiency , tuberculosis, melioidosis, and retroviral infections was negative. Contrast–enhanced CT of the brain and spine and magnetic resonance imaging (MRI) of the brain were normal. While initial spinal MRI raised concerns for an intramedullary neoplasm, serial imaging demonstrated a solitary thoracolumbar intramedullary abscess with extensive myelitis extending from the obex to conus. Radiological improvement on serial imaging further supported an infective rather than neoplastic aetiology , serving as a critical distinguishing feature. An aggressive multidisciplinary medical approach, comprising intravenous immunoglobulin, antimicrobials, antifungals, anti–tuberculous therapy , and rehabilitation resulted in significant clinical improvement without requiring neurosurgical intervention. Conclusion: This case emphasises the diagnostic complexity and rarity of paediatric ISCA, in which early imaging may be deceptive. Clinical vigilance, supported by serial spinal MRI in febrile children with acute limb weakness enables timely medical management, potentially avoiding surgical intervention and improving neurological outcomes.