CONGENITAL TUBERCULOSIS PRESENTING AS SEPSIS SYNDROME
Anand Kumar Agarwal, Manisha Agarwal*, D C Verma**
Department of Pediatrics, Hind Institute of Medical Sciences, Lucknow, **Department of Pediatrics, Saraswathi Institute of Medical Sciences, Hapur, Ghaziabad and Department of Obstetrics and Gynaecology*, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
Address for Correspondence
Karuna Thapar, Hno.9-A, Krishna Square, Near Shivala Mandir, Amritsar, Punjab, India-143001.
Email
kthapar2000@yahoo.com
Abstract
About 300 cases of congenital tuberculosis have been reported in world literature, nevertheless rarely with non-specific clinical manifestations. We report an infant with congenital tuberculosis who presented with sepsis and whose mother was diagnosed but partially treated case of pulmonary tuberculosis during antenatal period.
Keywords
Congenital tuberculosis, Sepsis.
Introduction
Clinically, congenital tuberculosis simulates other congenital infections such as syphilis or cytomegalovirus or bacterial sepsis. Congenital tuberculosis should be suspected if aggressive broad spectrum antibiotics are ineffective and tests for other congenital infections are negative, particularly if the mother is known to have tuberculosis and specially if recently diagnosed. Congenital tuberculosis is rare if mother has been on effective treatment (1). We report a case of congenital tuberculosis whose mother was a partially treated case of pulmonary tuberculosis.
Case Report
A 2 months old male baby presented with poor sucking for 4 days after birth, respiratory distress for 1½ months, fever, poor feeding and yellowish discoloration of body for 25 days and refusal to feed and lethargy for 10 days. Baby was 4th in birth order, full term normal delivery conducted by untrained dai at home. Baby cried immediately after birth and was given BCG. Baby was breastfed for 4 days and later cow's milk in 2:1 dilution was given with bottle as child could not suck the breast. Baby was given treatment by various local practitioners in the first 2 months to which he showed no response and was admitted to our hospital. Mother of the baby was diagnosed as a case of pulmonary tuberculosis in 2nd trimester of pregnancy at a local community health center and was prescribed Anti Tuberculosis Treatment (ATT). She took intermittent therapy. Mother when screened for tuberculosis at our hospital had healed lesions on X-ray. Sputum examination for Acid Fast Bacilli (AFB) was negative.

On physical examination, general condition of baby was very serious. Baby was lethargic, weighed 2.5 kgs with marked icterus, oral thrush, marked respiratory distress with subcostal recession, respiratory rate of 62/min, and diminished bilateral breath sounds. Abdomen was distended. Liver was enlarged 6 cms below costal margin, spleen was 4 cms in size. All neonatal reflexes were sluggish. Provisional diagnosis of severe septicemia was made, baby investigated and put on antibiotic and supportive therapy.

On investigations, Hemoglobin was 11.5 gms%, total white cell count was 12,700/cu mm (polymorphs 74%, lymphocytes 24%, eosinophils 2%). Total serum bilirubin was 8.8 mg/dl with direct serum bilirubin 6mg/dl. Alanine aspartase was 585 IU, Aminotransferase 415 IU. ESR was 60 mm/hr. Chest radiograph showed bilateral miliary mottling. Ultrasonograph of abdomen showed minimal bilateral pleural effusion. Smear of gastric aspirate was positive for Acid fast bacillus. Culture of gastric aspirate was also positive for Acid fast bacillus (report received later). Bacterial cultures of blood, urine, and cerebrospinal fluid (CSF) were negative. Serological testing for HIV was negative. Mantoux skin test was negative. Baby was put on ATT. After 4 days of ATT and supportive therapy, baby's condition kept on deteriorating and ultimately baby died.
Discussion
Tuberculosis in neonate can be either congenital (acquired in utero) or neonatal (acquired early in life from mother or contagious member). Hematogenous spread and aspiration of infected amniotic fluid accounts for approximately half the cases of congenital tuberculosis each (2,3). It is not always possible to be sure of route of infection in a particular neonate. Tuberculous bacillemia during pregnancy may result in infection of placenta or maternal genital tract transmitting the infection to fetus in utero (4,5). Although fetal infection directly from the mother's blood stream without the formation of a caseous lesion in placenta has been described in experimental animal models. It is unclear whether this happens in humans. In our case placental and genital tuberculosis could not be proved. Mother was definitely a partially treated case of pulmonary tuberculosis. Possibility of hematogenous spread cannot be ruled out. Beitzke (6) established the standardized criteria for distinguishing congenital from postnatally acquired tuberculosis in 1935. These criteria require that infant have proved tuberculous lesions and one of the following: lesions in the first few days of life, a primary hepatic complex, or the exclusion of postnatal transmission by the separation of infant at birth from the mother and other sources of infection. In the presented case, Beitzke criteria could not be fulfilled as patient approached 2 months after birth, but we consider the presented case involving miliary tuberculosis in an infant along with healed lesions in mother to be highly suspicious for diagnosis of congenital tuberculosis. When baby came to us probable diagnosis of severe septicaemia was made but on X-ray doubt of congenital tuberculosis arose which was later confirmed by gastric aspirate positive for AFB on culture and smear both. Hageman et al (8) found positive cultures for Mycobacterium tuberculosis in 10 out of 12 gastric aspirates. A positive AFB smear of gastric aspirate should be considered indicative of tuberculosis (9). Symptoms of congenital tuberculosis may be present at birth but more commonly begin by second or third week of life, median age at presentation is 24 days (range 1 to 84 days). When considering the timing of appearance of symptoms in the said case which was about 4 days and slowly progressing, it may be further evidence that suggests the diagnosis of congenital tuberculosis. Most frequent signs and symptoms of congenital tuberculosis are listed in table 1(2)

Table 1. Most frequent Signs and Symptoms of Congenital Tuberculosis
symptom Frequency (%)
Hepatosplenomegaly* 76
Respiratory distress* 72
Fever* 48
Lymphadenopathy 38
Abdominal distention* 24
Lethargy* or irritability 21
Ear discharge 17
Papular skin lesions 14
Jaundice*, vomiting, apnea, cyanosis, seizures, petechiae <10 each

*Sign or symptom found in presented patient

In the presented case, we found hepatosplenomegaly, respiratory distress, fever, abdominal distention, lethargy, and jaundice compatible with previous studies (3,9). It has been reported that patients with severe disease especially miliary tuberculosis are more likely to have abnormalities of liver function (LFT) (10). In the said case LFT'S were deranged. The disease in this patient was potentially preventable had preventive therapy been taken during pregnancy as is recommended when there is evidence of recent infection (1). But in said case mother hardly took any therapy and post natal period was not under expert care. In summary, congenital tuberculosis is a rare disease that is difficult to diagnose due to non-specific symptoms in infant and minimal or no symptoms in mother. A high index of suspicion is required for diagnosis. Screening for tuberculosis should be a part of routine prenatal examination especially in areas with increasing evidence of infection with initiation of prompt treatment after diagnosis.
Funding
None
Conflict of Interest
None
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Last Updated : Tuesday, August 01, 2006 Vol 3 Issue 8 Art #28
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Thapar K, Dhawan G. CONGENITAL TUBERCULOSIS PRESENTING AS SEPSIS SYNDROME. Pediatric Oncall [serial online] 2006[cited 2006 August 1];3. Art #28. Available From : http://www.pediatriconcall.com/Journal/Article/FullText.aspx?artid=412&type=J&tid=&imgid=&reportid=166&tbltype=
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