Congenital Tuberculosis

Suryakant Khopkar, Asawari Setigiri,

Vilas Jadhav, Mukesh Agarwal

Edited By: Deepak Seth

Tuberculosis infection in a female of reproductive age-group is associated with profound consequences, ranging from infertility to the transmission of infection in her new born. Congenital tuberculosis is a well established clinical entity, though until pre-chemotherapeutic era the reorganization of congenital tuberculosis was mainly academic, as the condition was always fatal.

Case report

A three months old infant weighing 4.8 kg was admitted with complaints of fever, cough and breathlessness since 3 days. The baby was delivered vaginally with birth weight of 2.8 kg following an uneventful pregnancy and labor. There was no history suggestive of tuberculosis contact, including in the mother.

On examination, the baby had respiratory rate of 60/min with intercostals retractions. Air-entry was decreased and crepts were heard on both sides. Liver and spleen were palpable 2 cm each below costal margin routine haematogram revealed normal total and differential counts with ESR of 45 at the end of 1 hr and no definite evidence of septicemia. The initial X-ray of the chest showed bilateral diffuse mottling with left upper zone emphysematous bulla. Blood gas analysis showed pH 7.35, PO2- 42, PCO2-49, Sat. O2-72% and HCO3 - 15. Blood culture was sterile. Mantoux test was negative. Baby's and mother HIV were negative. Baby was started on IV Ceftriaxone and Amikacin considering staphylococcus bronchopneumonia but the baby continued to have respiratory distress and high grade fever.

Couple of day's later, gastric lavage examination revealed the acid fast bacilli with Ziehl-Neelson's staining and fluorescent microscopy. The baby was started on anti-tubercular therapy with INH (5-10 mg/kg/day), rifampicin (15-20 mg/kg/day) and Pyrazinamide (25 mg/kg/day) with prednisolone (2 mg/kg/day). After 7 days of treatment, baby developed recurrent left focal seizures with hemiparesis. CSF examination then revealed proteins 54 mg% and sugar 48 mg% and total cells 40/cumm with polymorphs 50%. CSF ADA level was raised 10 units/L (normal 10 units/ L). CSF culture was sterile and ELISA test in CSF for TB antibodies was positive. CT scan of brain showed right cortical infarct with no evidence of basal exudates or hydrocephalus.

Patient succumbed on 22^nd day of admission i.e. after 2 weeks of anti-tubercular therapy. The mother's X-ray showed old calcified tuberculosis lesion at right upper zone but she was clinically asymptomatic.

Discussion

Until pre-chemotherapeutic era, recognition of the congenital tuberculosis was academic as the condition was always fatal. There have been approximately 300 reported cases in the medical literature. Surprisingly, there are few case reports from India despite of high prevalence of tuberculosis.

Recognition of congenital tuberculosis requires high index of suspicion as the manifestation are different from the older children. The disease usually manifest during first weeks of life but our patient presented little later. The common presenting manifestations are fever, respiratory distress, hepatomegaly, splenomegaly, irritability, prematurity and lymphadenopathy; sometimes indistinguishable from other causes of intrauterine or postnatal infection. Jaundice, seizure and meningitis are not very common, through may develop during the course of the disease. Infection of the fetus can occur either by transplacental route or secondary to ingestion or/and aspiration of infected amniotic fluid, usually at the time of delivery. Mother may be asymptomatic, though in some of them a radiological underlying focus is detectable.

Criteria for diagnosis of congenital tuberculosis were established in 1935 by Beitzke, which are still valid

1. The tuberculosis nature of the lesion must be proved.

· A primary complex in the liver is proof of congenital (intrauterine) origin

2. If there is no primary focus in the liver the infection is then only accepted as congenital if lesions are found in-utero, at birth or a few days later. In cases which manifest relatively later, all extrauterine sources of infection must be eliminated with certainty.

In present case, age of the child, presence of focus the mother and absence of infection in other contacts on screening, points towards a congenital origin of the disease.

Gastric aspirate for acid fast bacilli by Ziehl-Neelsen's staining, fluorescent microscopy or culture is very useful diagnostic too through over all yield is less than 20-30% with best available techniques.

Once the diagnostic of congenital tuberculosis is confirmed, with early treatment survival rate is approximately 45%. Association of tubercular meningitis with congenital tuberculosis is unusual and has poor outcome. While considering the prognosis of tuberculosis meningitis age is an important prognostic factor, and it is inversely related to mortality.

Conclusion

To conclude, early diagnosis of congenital tuberculosis depends on high index of suspicion, especially in endemic and susceptible high risk population, as the clinical manifestations are usually vague and investigations are unrewarding.