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.
References
1. Hudson FP. Clinical aspects of
5. SeatonA, Seaton D, LeitchAG.
8.
Rajiv K, Npomeeta G, Arvind
congenital tuberculosis.
C l i n i c a l
f e a t u r e s
o f
S. Congenital Tuberculosis.
Arch. Dis Child 1956; 31:
Tuberculosis. In: Crofton and
Indian Journal of Paediatrics
136-9
D o u g l a s '
R e s p i r a t o r y
2005; 72; 631-3
2 .
S r i
S S .
C o n g e n i t a l
4
t h
D i s e a s e s .
E d i t i o n ,
9. Brent W, Laartz MD, Hugo J.
Tuberculosis. In: Textbook of
B l a c k w e l l
S c i e n t i f i c
Congenital Tuberculosis and
P u l m o n a r y
a n d
E x t r a
Publications, London. 1989;
Management of Exposures in
Pulmonary
Tuberculosis ,
395-422.
a neonatal intensive care unit.
2nd edition, Interprint New
6 . B l a c k a l l P B .
I nfection Control and Hospital
Delhi 1995; 205
Tu b e r c u l o s i s : m a t e r n a l
Epidemiology 2002; 23 (10)
infection of newborn. Med J
573- 9
3. Cantwell MR, Shehab ZM,
Aust 1969; 1:1055-58
10. Hassan G, Qureshi W, Kadri
Costello AM et al. Brief
7. Hageman J, Shulman S,
SM. Congenital Tuberculosis.
r e p o r t :
C o n g e n i t a l
Schreiber M, Luck
JK Science 2006; 8(4) 193-4
tuberculosis. N Engl J Med
S.Congenital tuberculosis:
1994; 330: 1051-4
critical appraisal of clinical
4. Armstrong L, Garay SM.
findings and diagnostic
Tuberculosis and pregnancy
procedures. Paediatrics
and tuberculous mastitis. In:
1980; 66: 980-4
Rom WN, Garay SM eds
Tuberculosis . Boston. Little
Brown and Company; 1996;
689-98