CASE REPORT |
https://doi.org/10.5005/jp-journals-10081-1325 |
A Case Report on Disseminated Tuberculosis in a Newborn
1-3Department of Pediatrics, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India
Corresponding Author: Mangla Sood, Department of Pediatrics, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India, Phone: +91 9418453465, e-mail: drmanglasood@gmail.com
Received on: 11 July 2021; Accepted on: 02 August 2021; Published on: 15 April 2023
ABSTRACT
Congenital tuberculosis (CTB) is a rare and challenging diagnosis with high mortality. As one of the many differentials for newborn sepsis, it should be considered when neonates deteriorate despite broad-spectrum antibiotics. We present a case of a day 19, full-term Indian male neonate with fever, respiratory distress, and abdominal complaints. The response to antibiotics and supportive treatment was not encouraging, so he was evaluated for CTB which revealed disseminated lesions in the lungs, liver, and spleen with abdominal lymphadenopathy. Genexpert CB-NAAT test for Mycobacterium tuberculosis (MTB) DNA was positive. The neonate responded well on antitubercular therapy (ATT). We could not find the source of infection despite extensive evaluation of close contacts including the mother. We conclude that CTB should be taken into consideration when neonates with sepsis respond poorly to antimicrobial treatment in TB-endemic areas. Diagnostic workup should include obtaining a gastric aspirate sample for the detection of MTB DNA via PCR, and a thorough evaluation of the mother.
How to cite this article: Bhagat S, Sood M, Bhardwaj P. A Case Report on Disseminated Tuberculosis in a Newborn. Pediatr Inf Dis 2023;5(1):23-24.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient’s parents/legal guardians for publication of the case report details and related images.
Keywords: Case report, Congenital, Disseminated, Newborn, Perinatal, Tuberculosis.
CASE DESCRIPTION
A 19-day-old exclusive breastfed male neonate was brought to the Pediatric Emergency Department with complaints of fever, unwillingness to feed, and abdominal distention for the previous three days. Born in a hospital as a full-term vaginal delivery, he cried soon after birth, weighed 2,600 g, and was discharged on day 3. He was given the anti-hepatitis B and BCG vaccines at birth. On examination, he appeared lethargic, in respiratory distress with RR 78/minute, hypoxia, and SpO2 of 72% on room air. Systemic examination revealed diffuse lung crepitation, tympanic abdomen, with hepatosplenomegaly. A presumptive diagnosis of sepsis was made, broad-spectrum antibiotics were started along with supportive management including oxygen.
Anemia (Hb 6.8 g/dL), leukopenia (WBC count 3 × 109/L), thrombocytopenia (39,000 platelets/μL), increased CRP 102 mg/L, ferritin >2,000, and mildly raised ALT 64, AST 78 were reported in lab tests; renal function and electrolytes were normal. Blood cultures, urine, and CSF analyzes, as well as serology testing for CMV, Toxoplasma, rubella, and herpes simplex, were all negative.
Abdominal ultrasonography revealed hepatosplenomegaly, heterogeneous echotexture, and multiple diffuse hypoechoic lesions, along with the free liquid in the peritoneal cavity. There was porta hepatis and peri-pancreatic lymphadenopathy (maximum diameter of 15 mm) (Fig. 1). Both lung fields had diffuse reticulonodular infiltration on the chest radiograph. CT chest (Fig. 2) and abdomen (Fig. 3) confirmed CXR and abdomen USG findings. There were no air-fluid levels, pneumatosis intestinalis, pneumoperitoneum, and portal venous gas (pneumatosis hepatitis) on the abdomen X-ray, ruling out intestinal sepsis. Normal bone marrow aspiration ruled out hemophagocytic lymphohistiocytosis. The patient’s ongoing clinical deterioration placed TB as the most likely cause for the disseminated miliary granulomas. Genexpert CB-NAAT test of the gastric aspirate from the newborn for TB came out to be positive with sensitivity to rifampicin.
Fig. 1: Ultrasound abdomen shows hepatomegaly, span 7.6 cm, heterogeneous echotexture, multiple hypoechoic lesions in bilateral lobes measuring up to 3.6 mm in diameter. IHBR is not dilated
Fig. 2: CT lung shows multiple nodular diffusely scattered soft tissue lesions bilateral lung
Fig. 3: CT abdomen shows multiple hypodense lesions scattered in liver and spleen
For identifying the source of infection to the index case, the mother was thoroughly evaluated but all her reports were reported normal including the chest radiography, ultrasound of pelvic organs, HRCT chest, endometrial biopsy pathology, and PCR for TB. We could not comment on the placenta as the patient was delivered to another hospital. The parents were unaware of any sick contacts as such. Other family members, including the father, had negative chest X-rays, sputum for acid-fast bacilli, and tuberculin sensitivity tests.
The final diagnosis was disseminated tuberculosis, treatment initiated with antitubercular therapy (ATT) as per the National Tuberculosis elimination program of government.1 The newborn responded to treatment with increased activity and weight gain and was discharged home after 2 weeks. His parents bring him for regular follow-up, he is thriving well.
DISCUSSION
Cantwell et al. put forth the criteria for establishing congenital tuberculosis (CTB) diagnosis,2 and include a proven tuberculous lesion in a newborn, in addition to at least one of the following: (i) lesions in the first week of life; (ii) a primary focus of caseating hepatic granulomas; (iii) maternal genital tract or placental TB; and (iv) exclusion of postnatal transmission through sick contacts. Due to the inherent challenges in ascertaining whether the TB infection in the perinatal period is acquired congenitally or postpartum, perinatal TB is the preferred term over CTB.3 It is a rare infection, with only 300 cases reported.3 TB can be transmitted to the fetus via the placenta (i.e., vertical transmission) as hematogenous dissemination after rupture of a placental tubercle into the fetal circulation, from infected amniotic fluid swallowed by the fetus, or it can be transmitted through an infected genital TB lesion during vaginal birth.2 Inhalation of tubercle bacilli from close contact, contamination of labor equipment, or ingestion of infected milk can all cause postnatal illness.2 The most common signs and symptoms reported in children diagnosed with perinatal TB were hepatosplenomegalies in 76%, respiratory distress in 72%, fever in 48%, lymphadenopathy in 38%, and papular skin lesions in 14%.3 Sixty to seventy percent of the mothers had no clinical manifestations of TB.4
Our case shows an extremely unusual occurrence of perinatal tuberculosis, with symptoms appearing at 19 days of age, which is consistent with the average age of beginning of symptoms being between 14 days and 28 days.2 The significant gastrointestinal involvement with microabscess were most likely tuberculous lesions, with transmission via the umbilic vein or aspiration of infected amniotic fluid is a plausible explanation. However, we could not support the diagnosis with placental samples and liver biopsy. The screening of the source is an essential component, but we could not identify any potential latent or active MTB infection in his mother. In a review of 32 cases of CTB, 24 of the mothers were also asymptomatic.5 Congenital tuberculosis is rare and fatal with an estimated incidence of 2% in tuberculosis endemic countries.6 Clinicians should get familiar with the symptoms because early detection and treatment can help to avert death.
REFERENCES
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