ISSN - 0973-0958

Pediatric Oncall Journal

Congenital Tuberculosis Presenting As Sepsis Syndrome 01/09/2014 00:00:00

Congenital Tuberculosis Presenting As Sepsis Syndrome

Karuna Thapar, Gaurav Dhawan.
Department of Pediatrics, Govt. Medical College, Amritsar.

Karuna Thapar, Hno.9-A, Krishna Square, Near Shivala Mandir, Amritsar, Punjab, India-143001.
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.
Congenital tuberculosis, Sepsis.
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.
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.
Compliance with Ethical Standards
Funding None
Conflict of Interest None
  1. American Thoracic Society. Medical Section of the American Lung Association: treatment of tuberculosis and tuberculous infection in adults and children. Am Rev Respir Dis 1986; 134:355-363.  [PubMed]
  2. Starke JR, Smith MHD. Tuberculosis. Infectious disease of the fetus and newborn infant. 5th Edition.Philadelphia: WB. Saunders Company 2001, 1179-97.
  3. Cantwell MF, Shehab ZM, Castello AM, et al. Brief report: congenital tuberculosis. N Engl J Med. 1994,330(15): 1051-4.  [CrossRef]  [PubMed]
  4. Smith MHD, Teele DW. Tuberculosis. In: Remington JS, Klein JO, eds. Infectious diseases of the fetus and newborn infant. 3rd ed. Philadelphia: W.B. Saunders, 1990:834-47.  [PubMed]  [PMC free article]
  5. Vallejo JG, Starke JR. Tuberculosis and pregnancy. Clin Chest Med 1992; 13:693-707.  [PubMed]
  6. Beitzke H. Uber die angeborene tuberkulose Infektion. Ergeb Ges Tuberk Forsch 1935; 7:1-30.
  7. Klotz SA. Penn RL: Acid fast staining of urine and gastric contents is an excellent indication of mycobacterial disease. Am Rev Respir Dis. 1987, 136:1197-8.  [CrossRef]  [PubMed]
  8. Hageman J, Shulman S, Schreiber M, el al. Congenital tuberculosis: Critical reappraisal of clinical findings and diagnostic procedures. Pediatrics 1980, 66: 980-4.  [PubMed]
  9. Mazade MA, Evans EM, Starke JR, et al. Congenital tuberculosis presenting as sepsis syndrome. Case report and review of the literature. Pediatr Infect Dis J. 2001; 20: 439-42.  [CrossRef]  [PubMed]
  10. Korn RJ, Kellow WF, Heller P, el al. Hepatic involvement in extrapulmonary tuberculosis:Histologic and functional characteristics. Am J Med. 1959; 27: 60-71.  [CrossRef]

Cite this article as:
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License
Disclaimer: The information given by is provided by medical and paramedical & Health providers voluntarily for display & is meant only for informational purpose. The site does not guarantee the accuracy or authenticity of the information. Use of any information is solely at the user's own risk. The appearance of advertisement or product information in the various section in the website does not constitute an endorsement or approval by Pediatric Oncall of the quality or value of the said product or of claims made by its manufacturer.
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0