Nigerian Journal of
Paediatrics 2011; 38(2):100-103
CASE REPORT
A. A
Orogade
Congenital tuberculosis: a case report
WN
Ogala
R.
Onalo
Received: 28 February
2011
Abstract: Congenital
tuberculosis
illustrate
the
difficulty
in
Accepted: 18 May
2011
is insufficiently
understood and
identifying such
infants and also to
has been rarely
reported even in
sensitize the medical
practionner in
AA Orogade ( ),
Ogala W.N,
areas endemic for the
disease.
TB endemic areas of the
need for
Onalo R.
Unless a high index of
suspicion is
etiologic diagnosis in
congenital
Department of
paediatrics
maintained, the
diagnosis can be
pneumonias as well as
for antenatal
Ahmadu Bello
University
missed. A case of
congenital
screening for TB in
mothers at risk.
Teaching Hospital
Zaria-Nigeria
tuberculosis is herein
reported to
Email:
orogade@yahoo.com
Case
report
Serological testing
f or
congenital infections and
human immunodeficiency
virus (HIV) were
A five day old male
full term infant presented with
negative. Initial chest
radiograph showed bilateral
two days history of
fever, noisy breathing and
lung parenchymal
infiltrates (Fig1).
excessive crying. . The
infant's mother, a 20 year old
undergraduate
university student had had a febrile
illness 4 months before
delivery, was treated with
antibiotics and fully
recovered. She had remained
asymptomatic after that
and denied exposure to active
tuberculosis. The baby
whose birth weight was 3300g
now weighed 3280g.
Physical examination revealed
a temperature of 38 C,
irritability, central cyanosis,
°
severe respiratory
distress, moderate jaundice, few
bilateral small sized
inguinal lymph node swellings
and a papular skin
eruption with an erythematous
Echocardiography study
was normal
background. He was
moderately tachypneic
The baby received
intravenous cefuroxime and
(RR=88/min), had severe
subcostal and intercostal
intramuscular
gentamycin for five days but
recessions, with
decreased breath sound intensity and
respiratory symptoms
worsened with virtually absent
wide spread coarse
crepitations. The baby had
breath sounds in the
right upper and mid lung zones.
hepatomegaly of 5cm
below the right costal margin
Repeat chest
roentgenography then revealed
and a splenomegaly of
2cm. There was no
collapsed right upper
lung fields (Fig. 2).
cardiomegaly or
evidence of cardiac failure and
examination of other
systems was essentially normal.
His white blood cell
count was 9,900 per cubic
millimeter with 44.4%
polymorphonuclear cells,
4 7 . 3 %
l y m p h o c y t e s
,
6 . 2 %
m o n o c y t e s
,
1.8%eosinophils and
basophils 0.3%. Hematocrit
was 55%. Bacterial
cultures of blood, cerebrospinal
fluid and urine were
negative. Biochemical analysis
of CSF was normal and
culture, negative. Serum
C
oncentration of total
bilirubin was 130
μ mol/L.
101
Antibiotic regime was
changed to Ceftriaxone with
Discussion
some clinical and
radiological improvement within
six days. However,
there was persistence of moderate
Congenital tuberculosis
is defined as tuberculosis
respiratory distress
with tachypnea, intercostal and
occurring in infants
caused by M.
tuberculosis
subcostal recessions
with respiratory rates ranging
infection during the
intrauterine life or before
between 64/min and
74/min. He was discharged on
complete passage
through the birth canal . Diagnostic
1
parents request to the
neonatal clinic and had short
criteria for congenital
tuberculosis were proposed in
duration appointments
for close monitoring. Chest
1955 . Cantwell later
made a review in which there
2
3
radiography was
repeated about three weeks after
should be proven
tuberculosis lesion in the infant plus
discharge which showed
progressive lung disease
one of the following:
lesions occurring in the first
with homogenous opacity
of the left and right upper
week of life, a primary
hepatic complex, maternal
zones (Fig. III). By
the 7 week of life, the child was
th
genital tract or
placental tuberculosis and exclusion of
failing to thrive; he
weighed 3250g as compared to
postnatal transmission
by thorough investigation of
birth weight of
3300g.
contacts. Congenital
tuberculosis is believed to be
rare and fewer than 300
cases have been reported
worldwide by 1989 :
Blackall et al found three
4,5
6
affected patients among
100 infants of mothers with
active tuberculosis,
but in two other series
4
no
affected patients were
found among 260 and 1369
such infants. In this
area of tuberculous endemicity
however, there is
insufficient local literature to give
an accurate incidence
of congenital tuberculosis. This
may be due to the
difficulty in fulfilling the case
definition of
congenital tuberculosis.
Tuberculous bacillaemia
during pregnancy may
result in infection of
the placenta or the maternal
genital tract. Such
infection may then be transmitted
Screening for
congenital tuberculosis was initiated at
to the fetus by
hematogenous spread from the
this point. Tuberculin
skin test (Mantoux test) was
placenta to the
umbilical vein or by the aspiration or
negative. The mother
was also screened for
ingestion of amniotic
fluid contaminated by placental
tuberculosis and found
to have a Tuberculin Skin Test
or genital infection
either before delivery or at the
reaction of 18mm, and
an ESR of 34mm/hr. Her chest
time of delivery. This
is as opposed to acquired
r a d i o g r a p
h
s h o w e d
s i g n i f i c a n
t
h i l a r
tuberculosis which is
contracted at any post natal age
lymphadenopathy. She
was not coughing and so
though the most usual
contact of postnatal infection is
could not produce
sputum. Endometrial biopsy was
also the mother. What
differentiates the congenital
not done. She was found
to be sero negative for HIV.
from tuberculosis
acquired in early post natal life then
The baby then had a
diagnostic BCG test which
is that there has to be
proof of such antenatal
yielded an accelerated
reaction with formation of an
transmission. Usually
an endometrial biopsy done
induration in two days
and scar formation within
shortly after delivery
that shows the presence of acid
three weeks of
administration.
fast bacilli is
confirmatory of the diagnosis. A
The baby was then
commenced on streptomycin,
diagnosis of congenital
tuberculosis in this patient
isoniazid and
rifampicin with significant clinical
was not initially
entertained, but became a
response within three
weeks of initiation of therapy.
consideration after he
did not respond clinically or
By the 10 week of life
his weight had increased by
th
radiologically to
conventional first and second line
1150g to 4400g at an
average of 383g/week.
regimes for common
neonatal infections.
Complete resolution of
clinical and radiographic
The median age at
presentation in most reported cases
features was noted at
16weeks and 24 weeks
was 24 days (range
1-84) . The patient in this report
7
respectively.
was typical with
respect to age at presentation.
Respiratory distress,
fever and hepatosplenomegaly
are the nonspecific
symptoms and signs that
characterize congenital
tuberculosis , with which our
8
patient also presented.
These signs could be present
also in bacterial
sepsis, other congenital infections
such as
cytomegalovirus, herpes simplex virus, HIV,
toxoplasmosis, syphilis
and malaria.
Making an
early diagnosis of
tuberculosis in a neonate is
therefore difficult and
requires a high index of
102
Antibiotic regime was
changed to Ceftriaxone with
Discussion
some clinical and
radiological improvement within
six days. However,
there was persistence of moderate
Congenital tuberculosis
is defined as tuberculosis
respiratory distress
with tachypnea, intercostal and
occurring in infants
caused by M.
tuberculosis
subcostal recessions
with respiratory rates ranging
infection during the
intrauterine life or before
between 64/min and
74/min. He was discharged on
complete passage
through the birth canal . Diagnostic
1
parents request to the
neonatal clinic and had short
criteria for congenital
tuberculosis were proposed in
duration appointments
for close monitoring. Chest
1955 . Cantwell later
made a review in which there
2
3
radiography was
repeated about three weeks after
should be proven
tuberculosis lesion in the infant plus
discharge which showed
progressive lung disease
one of the following:
lesions occurring in the first
with homogenous opacity
of the left and right upper
week of life, a primary
hepatic complex, maternal
zones (Fig. III). By
the 7 week of life, the child was
th
genital tract or
placental tuberculosis and exclusion of
failing to thrive; he
weighed 3250g as compared to
postnatal transmission
by thorough investigation of
birth weight of
3300g.
contacts. Congenital
tuberculosis is believed to be
rare and fewer than 300
cases have been reported
worldwide by 1989 :
Blackall et al found three
4,5
6
affected patients among
100 infants of mothers with
active tuberculosis,
but in two other series
4
no
affected patients were
found among 260 and 1369
such infants. In this
area of tuberculous endemicity
however, there is
insufficient local literature to give
an accurate incidence
of congenital tuberculosis. This
may be due to the
difficulty in fulfilling the case
definition of
congenital tuberculosis.
Tuberculous bacillaemia
during pregnancy may
result in infection of
the placenta or the maternal
genital tract. Such
infection may then be transmitted
Screening for
congenital tuberculosis was initiated at
to the fetus by
hematogenous spread from the
this point. Tuberculin
skin test (Mantoux test) was
placenta to the
umbilical vein or by the aspiration or
negative. The mother
was also screened for
ingestion of amniotic
fluid contaminated by placental
tuberculosis and found
to have a Tuberculin Skin Test
or genital infection
either before delivery or at the
reaction of 18mm, and
an ESR of 34mm/hr. Her chest
time of delivery. This
is as opposed to acquired
r a d i o g r a p
h
s h o w e d
s i g n i f i c a n
t
h i l a r
tuberculosis which is
contracted at any post natal age
lymphadenopathy. She
was not coughing and so
though the most usual
contact of postnatal infection is
could not produce
sputum. Endometrial biopsy was
also the mother. What
differentiates the congenital
not done. She was found
to be sero negative for HIV.
from tuberculosis
acquired in early post natal life then
The baby then had a
diagnostic BCG test which
is that there has to be
proof of such antenatal
yielded an accelerated
reaction with formation of an
transmission. Usually
an endometrial biopsy done
induration in two days
and scar formation within
shortly after delivery
that shows the presence of acid
three weeks of
administration.
fast bacilli is
confirmatory of the diagnosis. A
The baby was then
commenced on streptomycin,
diagnosis of congenital
tuberculosis in this patient
isoniazid and
rifampicin with significant clinical
was not initially
entertained, but became a
response within three
weeks of initiation of therapy.
consideration after he
did not respond clinically or
By the 10 week of life
his weight had increased by
th
radiologically to
conventional first and second line
1150g to 4400g at an
average of 383g/week.
regimes for common
neonatal infections.
Complete resolution of
clinical and radiographic
The median age at
presentation in most reported cases
features was noted at
16weeks and 24 weeks
was 24 days (range
1-84) . The patient in this report
7
respectively.
was typical with
respect to age at presentation.
Respiratory distress,
fever and hepatosplenomegaly
are the nonspecific
symptoms and signs that
characterize congenital
tuberculosis , with which our
8
patient also presented.
These signs could be present
also in bacterial
sepsis, other congenital infections
such as
cytomegalovirus, herpes simplex virus, HIV,
toxoplasmosis, syphilis
and malaria.
Making an
early diagnosis of
tuberculosis in a neonate is
therefore difficult and
requires a high index of
103
suspicion. Tuberculosis
may be suspected in a sick
progressed rapidly from
bronchopneumonic changes
neonate who has
clinical features of septicemia, but
to lung collapse and
only improved significantly
whose response to
adequate doses of appropriate
when anti tuberculous
therapy was commenced.
broad spectrum
antibiotics and supportive therapy is
Military pattern is
common in infants as well as
poor. An important clue
could also be maternal or
Hilar/mediastinal
lymphadenopathy
and
family history of
tuberculosis; however it is not
parenchymal
infiltrates. Some infants have normal
unusual that the
diagnosis of infection in the infant
findings on chest
radiographs early in the course of
rather leads to the
discovery of tuberculosis in the
the disease and later
rapidly develop profound
mother. Indeed in most
series
8, 9
as indeed in this
index
radiological
abnormalities. Accelerated BCG
case, mothers are
asymptomatic at the time of their
response as was
observed in this patient should be
infant's
diagnosis.
considered as a
diagnostic tool.
Acid fast stains of
smears and mycobacterial cultures
Response to anti
tuberculous therapy is usually
from multiple sites:
gastric aspirates, endotracheal
dramatic with full
recovery and normal lung function
aspirates, CSF, open
lung biopsy and liver biopsy are
thereafter as in this
patient. The place of therapeutic
necessary to make a
diagnosis . Many infants with
2
trials as diagnostic
tool may become significant in
congenital tuberculosis
have abnormal findings on
resource limited
settings where diagnosis could
chest radiographs .
This patient's roentenogram
10
easily be
missed.
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