A 28 year old female, known to have type I DM presented to the emergency room (ER) with history of backache and lower limb weakness. Contrast MRI of the lumbosacral region demonstrated loss of disc space with paraspinal collection at L3-4 extending into bilateral iliopsoas muscle suggesting tuberculosis. After work up, the patient was started on four anti-tubercular drugs (ATT) regime of HRZE as per the protocol. After initial improvement in clinical and neurological status, the patient returned with relapse of back pain after 5 months of therapy. The repeated radiology demonstrated re-collection of organised pus. The needle aspiration of pus along with Xpert MTB/RIF and liquid culture (MGIT) both showed the presence of MTB resistant to rifampicin. Under USG guidance, a malecot catheter was inserted for drainage of the abscess. Patient was started on modified ATT and planned for surgical intervention and fixation in case of non-improvement or deterioration. After 2 months, the patient presented with high grade fever and discharge from the abscess site for which she was brought to the emergency department. MRI lumbosacral spine revealed infective pathology at L3/L4 segment with associated intra and extra-spinal abscesses causing neural compression in comparison with that of previous scans report (Fig. 1). Suspecting secondary infection, pigtail insertion was done to drain the abscess and cultures were sent for two consecutive days. Aerobic culture of the sample did not show growth of any bacteria and anaerobic culture showed growth of bacteria sensitive to metronidazole. The latter was identified as   Peptoniphilus asaccharolyticus   in both the samples by MALDI-TOF MS. Antibiotic sensitivity was put up by agar dilution method according to CLSI guidelines M11-A8 2012 which was sensitive to clindamycin, cefoxitin, metronidazole, imipenem and piperacillin-tazobactam with MIC breakpoints of 0.25, 4, 0.25, 0.031 and 0.125 (mg/L) respectively. With the culture report, the patient was started on metronidazole I/V 500 mg TDS and the patient's clinical symptoms like discharge of pus and fever drastically improved. Metronidazole was continued for a period of 14 days along with ATT. At the end of 14 days, patient had no signs of active pus discharge and there was complete resolution of fever. Follow up MRI after 14 days also revealed significant reduction in the loculated abscesses in the right iliopsoas muscles while the rest of the findings grossly remained the same (Fig. 2). Patient was discharged with continuation of oral metronidazole for five more weeks along with anti-tubercular drugs and insulin and surgical intervention once the secondary infection settled.