CASE REPORT

Niger J Paed 2012; 40 (1): 93 –96

Peterside O

Congenital tuberculosis: A case

report and review of the literature

Adeyemi OO

Kunle - Olowu OE

Akinbami FO

Omene J

Frances AD

DOI:http://dx.doi.org/10.4314/njp.v40i1.20

Accepted: 20th June 2012

Abstract Congenital tuberculosis

TB) is a rare infection transmitted

have been reported worldwide till

date and to the knowledge of the

1

(

Peterside O

(

) Adeyemi OO

from a mother to her foetus, either

through an infected placenta or am-

niotic fluid. Congenital tuberculosis

was previously thought to be rare

but recent changes in the epidemiol-

ogy of TB, have resulted in an in-

authors, there have been only₂_-₄three

reported cases in Nigeria. We

herein report a case of congenital

tuberculosis with a review of other

published cases in this high TB

prevalent region of Southern Nige-

ria with the aim of creating aware-

ness of its existence in this region.

Kunle –Olowu OE, Akinbami FO

Omene J, Frances AD

Department of Paediatrics and

Child Health.

Niger Delta University Teaching

Hospital, Yenagoa, Beyelsa State,

Nigeria.

Email: docolyemen@yahoo.com

Tel: +2348055855327.

1

creased risk. Affected infants usu-

ally present with non specific signs

and symptoms, hence a high index

of suspicion is required to make a

diagnosis. Fewer than 300 cases

Key words: Congenital tuberculo-

sis, case report, miliary tuberculosis

Introduction

predominantly breastfed for four weeks, then supple-

mentary feeds with infant formula was added. He was

yet to achieve any developmental milestone.

The infant was the only child of a cohabiting couple. His

mother was 19 years old, unemployed and stopped her

education at junior secondary school (JSS 2). Father was

a 28year old civil servant with secondary level of educa-

tion. They all lived in a one room apartment with poor

ventilation (one window).

Congenital tuberculosis defines tuberculosis in infants of

women who have pulmonary or placental tuberculosis. It

results from hematogenous spread through the umbilical

vein to the fetus with primary lesions in the liver or from

aspiration or ingestion of infected amniotic fluid in utero

or during delivery, with pulmonary and gastrointestinal

5

disease predominating. It is of diagnostic consideration

in areas of high prevalence of adult tuberculosis like

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Nigeria which has₇the fourth highest burden of tubercu-

On examination at presentation, he was restless, in respi-

losis in the world.

ratory distress, severely pale, febrile (temperature-

oC

7.8 ), and mildly dehydrated with oral thrush. He had

3

Case report

significantly enlarged lymph nodes in both the posterior

auricular and right cervical regions. They were discrete,

non tender and measured about 3cm in size. His occipi-

tofrontal circumference was 37cm (microcephaly),

length was 43cm (77% of expected), weight 3.3kg (55%

of expected).

I.G, a 12 week old male child, was admitted to the Niger

Delta University Teaching Hospital (NDUTH) follow-

ing referral from the Federal Medical Center (FMC)

Yenagoa with complaints of difficulty with breathing

and poor weight gain from birth, cough of nine weeks

duration, swelling of the left side of the neck of nine

weeks duration, fever of 10 days duration and passage of

frequent watery stools of two days duration.

He was tachypnoeic with a respiratory rate of 80cycles

per minute, with vesicular breath sounds and coarse

crepitations in both lung fields. There was tachycardia

with a pulse rate of 160 beats per minute with normal

heart sounds. The liver and sleen were both palpable

6cm and 4cm below the right and left costal margins

respectively. He had hypotonia in all the limbs with cor-

tical fisting, and depressed deep tendon reflexes.

Pregnancy was unsupervised and carried to term.

Mother had cough from the 5th month gestation that was

treated with unknown drugs bought over the counter.

The cough was productive of whitish, non blood stained

sputum. It resolved four weeks prior to delivery. Deliv-

ery was supervised by a traditional birth attendant.

Baby I G had not received any immunization. He was

He was initially managed as a case of septicaemia with

intravenous antibiotics and was also transfused with

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4

blood. Investigations done included: full blood count

and differentials: packed cell volume of 19%, white cell

count of 11.6 x10 /l with predominant lymphocytosis.

Discussion

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Congenital tuberculosis is very rare because the most

common result of female genital tract tuberculosis is

Retroviral screening for mother and child were both

negative and malaria parasite was also negative. Eryth-

rocyte sedimentation rate was 12mm/hr; Cerebrospinal

fluid analysis was normal; Liver function test showed

elevated liver enzymes ; the cytological evaluation of

the fine needle aspiration of the cervical lymph node

showed granulomatous inflammation. The child’s chest

x-ray showed nodular infiltration in both lung fields,

suggestive of miliary tuberculosis (fig.1) while his

mother’s chest x-ray showed hilar infiltrates (fig. 2).

The maternal Mantoux test was positive with 20mm

induration. Funduscopic examination of the infant’s

retina by the ophthalmologist to rule out intra uterine

infection was normal. His other household contacts

5

infertility. Two possible routes of in-utero infection are

postulated; either from hematogenous infection through

the umbilical vein with primary lesions in the liver or

from prenatal aspiration of infected amniotic fluid wi₅th

pulmonary and gastrointestinal disease predominating.

According to the revised diagnostic criteria for congeni-

8

tal tuberculosis by Cantwell et al in 1994, the infant

should have proven tuberculous lesion and at least one

of the following: symptoms occurring in the first week

of life, a primary hepatic TB complex, maternal genital

tract or placental tuberculosis and exclusion of postnatal

transmission by thorough investigation of contacts. The

index patient fulfilled these diagnostic criteria, in that he

had miliary tuberculosis as shown in the chest x-ray and

tuberculosis of the superficial glands, as confirmed by

(

father and grand mother) both had negative mantoux

tests and normal chest xrays.

.

histologic examination as well as a dramatic response to

anti-TB drugs. In addition, his symptoms started from

the first week of life and post natal transmission was

excluded as apart from his mother, his other household

contacts tested negative to screening tests.

Fig 1: Patient’s

chest x-ray

The most common presentation of congenital tuberculo-

sis is respiratory distress, lethargy, poor feeding, fever,

irritability, abdominal_-₁₀distension, failure to thrive and

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hepatosplenomegaly.

The index case presented with

most of these features. These signs could also be present

in bacterial sepsis and other congenital infections such

as toxoplasmosis, rubella, cytomegalovirus, herpes sim-

plex and syphyllis. It is not surprising therefore that the

index patient was initially managed for septicaemia with

intravenous antibiotics. Tuberculosis was only suspected

as a result of his poor clinical response. Similar to this

Fig 2: Maternal

chest x-ray

2

case, Orogade et al, in Zaria, reported a case of a five

day old term baby who was managed for pneumonia

with intravenous antibiotics for two weeks without im-

provement and was discharged home on parental re-

quest. Their patient re-presented at seven weeks and was

found to be failing to thrive. It was only then that TB

was suspected and a diagnosis made on screening. Lee

th

11

On the 14 day of admission, the child had lost 16% of

et al also reported a case of a preterm neonate who was

his weight with persistence of fever and respiratory dis-

tress. Anti-tuberculous therapy was commenced using:

rifampicin, isoniazide, pyrazinamide, and streptomycin.

Streptomycin was subsequently discontinued because

the child had prolonged bleeding from the injection site.

His mother was also commenced on anti-tuberculous

drugs.

admitted at birth and managed for pneumonia with anti-

biotics. Their patient, however continued to deteriorate

until he died at 65 days of age. The diagnosis of con-

1

2

genital TB was only made at autopsy. Agarwal et al

1

3

and Ray et al in Indi₄a have also reported similar cases.

1

Patel and DeSantis, after reviewing published case

reports, recommended that congeinital TB should be

considered in the differential diagnosis of newborns who

have (1) nonresponsive or worsening pneumonia, espe-

cially in regions of high rates of TB, (2) non specific

symptoms but have a mother diagnosed with TB, (3)

high lymphocyte counts in the cerebrospinal fluid with-

out an identified bacterial pathogen or (4) fever and

hepatosplenomegaly. The index patient fulfilled the first,

second and fourth criteriae.

Three weeks after commencement of anti-tuberculous

drugs, the infant showed remarkable improvement with

weight gain, absence of fever and respiratory distress,

and reduction in size of the enlarged lymph nodes. Vital

signs became normal. He was discharged home six

weeks after admission on parental request to complete

eight months of anti-tuberculous drugs as an out-patient.

The difficulties in the diagnosis of pulmonary TB in the

index patient was compounded by the paucity of mater-

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5

nal symptoms. His mother had cough for four months in

pregnancy which subsided before delivery. She received

unknown medications bought over the counter as she did

not have any antenatal care.₁₅Other authors in Northern

The index patient fortunately, even with late presenta-

tion and diagnosis, showed a good response to a combi-

nation of three anti-tuber₃culous drugs; isoniazid, rifam-

2

picin and pyrazinamide. There are other case reports in

2

21-

Nigeria and South Florida also reported paucity of

t₂h₃_.e literature of successful treatment of congenital TB

1

6

maternal symptoms. In a review by Abughali et al,

twenty four of thirty two mothers of infants diagnosed

with congenital TB were asymptomatic. The lack of

antenatal diagnosis in the mother of the index patient

highlights the need for early detection of the disease

during pregnancy with institution₁_,o₉f appropriate therapy

to prevent infection of the foetus.

Conclusion

8

,16,17

have shown that complications of

Several authors

Congenital tuberculosis, though rare, should be consid-

ered in an infant diagnosed with pneumonia that is resis-

tant to antibiotic therapy especially in areas of high tu-

berculosis prevalence. Also there is need for anti tuber-

culosis therapeutic trial to be initiated as diagnostic tool

in resource limited settings where diagnosis could easily

be missed. A high index of suspicion is required towards

diagnosis of tuberculosis in pregnancy. Screening for

tuberculosis should be part of the routine prenatal care at

the slightest suspicion of tuberculosis.

late diagnosis of congenital TB include meningitis, mili-

tary TB and otitis media, resulting in seizures, deafness,

and death. It is therefore not surprising that the index

case who presented at tw₈elve weeks of age, had miliary

1

tuberculosis. Peng et al reviewed imaging findings in

1

43 cases of congenital tuberculosis and 46.8% of them

demonstrated a miliary pattern. Similarly, Hagemann

showed that 50% of infants with congenital TB pre-

sented with miliary pattern of pulmonary involvement.

17

Congenital TB if left untreated or if treatment is com-

menced late, may have a fatal outcome as were the ca₁₃ses

Conflict of interest: none

Funding: None

1

19

presented by Lee et al, Chen et al, and Ray et al. It

is recommended that treatment regimens for congenital

TB should contain at least two or preferably three₉d_,₂r₀ugs

to which the organisms are likely to be susceptible.

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