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  
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  
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,  
Tel: +2348055855327.  
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  
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  
disease predominating. It is of diagnostic consideration  
in areas of high prevalence of adult tuberculosis like  
Nigeria which has7 the fourth highest burden of tubercu-  
On examination at presentation, he was restless, in respi-  
losis in the world.  
ratory distress, severely pale, febrile (temperature-  
7.8 ), and mildly dehydrated with oral thrush. He had  
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  
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.  
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  
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-  
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  
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  
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  
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  
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-  
genital TB was only made at autopsy. Agarwal et al  
and Ray et al in Indi4a have also reported similar cases.  
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-  
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-  
picin and pyrazinamide. There are other case reports in  
Nigeria and South Florida also reported paucity of  
t2h3.e literature of successful treatment of congenital TB  
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.  
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  
tuberculosis. Peng et al reviewed imaging findings in  
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.  
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  
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TB should contain at least two or preferably three 9d,2r0ugs  
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