Preterm Twins Born to a Mother with Miliary Tuberculosis: Importance of Early Recognition and Prompt Response in Infection Control to Manage Congenital Tuberculosis Exposure in a Neonatal Intensive Care Unit.

Delayed diagnosis of congenital tuberculosis (TB) in the neonatal intensive care unit (NICU) is a serious problem in terms of infection control. Here, we report our preemptive infection control activities implemented after the diagnosis of miliary TB in a mother of preterm twins (index twins, NB1 and NB2) in the NICU. In addition, we reviewed previous case reports of congenital TB exposure in the NICU setting. Immediately after diagnosing miliary TB in the mother, the index twins were isolated before their TB diagnosis and received preemptive anti-TB medication; contact investigations were also conducted. Eventually, NB1 was diagnosed with congenital TB at 29 days of age, and NB2 showed no definite evidence of TB. Through contact investigation, 11 of the 16 exposed infants received isoniazid prophylaxis and no positive tuberculin skin test results were obtained after 3 months. One of the 31 exposed healthcare workers showed new interferon-gamma release assay conversion. Moreover, our case showed a much shorter contagious period compared to that in previous reports (8 versus 17-102 days). This suggests that a high index of suspicion and prompt measures can help prevent congenital TB outbreaks and reduce the burden of infection control activities in the NICU.

Congenital tuberculosis in an extremely preterm infant conceived after in vitro fertilization: case report.

BACKGROUND: Congenital tuberculosis is a rare manifestation of tuberculosis. The diagnosis is often delayed, especially in preterm neonates because of the non-specific clinical presentation and the lack of awareness of maternal disease prior to pregnancy. CASE PRESENTATION: We report a case of congenital tuberculosis in an infant born at 24 weeks of gestation to a mother who presented with uncontrolled seizures during preterm labor. Maternal diagnosis was initially made by placental pathology, and later confirmed by isolation of Mycobacterium tuberculosis in urine, gastric aspirates and sputum. Full screening was performed on the newborn infant, and both mother and infant were successfully treated for tuberculosis with a four drug regimen. CONCLUSION: Pregnancy can exacerbate latent tuberculosis and women originating from endemic areas are especially susceptible. The best way to prevent congenital tuberculosis is to have a high index of suspicion and identify and treat tuberculosis in pregnant women.

Rifampicin pharmacokinetics in extreme prematurity to treat congenital tuberculosis.

Little evidence is available on the pharmacokinetics of antituberculous medication in premature infants. We report rifampicin (RMP) pharmacokinetics in an extremely premature, low-birthweight female infant born to a mother with known miliary tuberculosis. Intravenous RMP, isoniazid (INH), ciprofloxacin and amikacin were used, as the enteral route was not possible. Area under the curve calculations revealed low average RMP concentrations at doses of 5-10 mg/kg. We review the literature with regard to the dosing regimen and therapeutic drug levels of RMP and INH in premature infants and discuss issues of management. Evidence from this case suggests 10 mg/kg/day is the minimum dose required.

Usefulness of postmortem computed tomography before forensic autopsy for alerting forensic personnel to tuberculosis infection.

Since May 2009, we have performed multislice computed tomography (MSCT) prior to forensic autopsy for cases of suspicious death. In the present case, innumerable widely scattered nodules in both pulmonary fields on MSCT were indicative of miliary tuberculosis (TB). At autopsy, both lungs were submerged in formalin fluid immediately after removal from the body. Miliary TB was finally diagnosed based on microscopic findings. TB is a disease that autopsy room workers need to be aware of to protect themselves. Unfortunately, because little medical information about deceased individuals is usually available before forensic autopsy, the diagnosis of TB is frequently not made until autopsy. This leads to a much higher incidence of TB in autopsy room staff members even if they wear protective clothing. Therefore, MSCT before forensic autopsy may identify suspected cases of miliary TB in advance and thus help to prevent TB infection in forensic autopsy personnel.

Tuberculosis prevalence at autopsy: a study from North India.

Tuberculosis (TB) is an important cause of morbidity and mortality. This study attempts to determine the prevalence of TB in autopsies. Of 768 autopsies, 39 cases were diagnosed as TB. These were retrieved and re-examined. It was noted that in a significant number of patients with TB was only revealed after autopsy. This has important implications as they may well have been a source of transmission to the general public and health-care providers.

Feeding intolerance due to connatal tuberculosis in a prematurely born infant.

A prematurely born infant had three episodes of feeding intolerance in the first three weeks after birth. In the post-partum period, his mother, who was from the Ukraine, had a respiratory arrest; unusually, a high-resolution computerised tomograph demonstrated miliary tuberculosis (TB). As a consequence, and due to the continuing ill health of the infant, gastric aspirates were sent from the infant. Acid fast bacilli were seen on microscopy. Variable nucleotide tandem repeat analysis of acid fast bacilli facilitated the rapid diagnosis of connatal TB. We conclude that connatal TB should be considered in a prematurely born infant poorly responsive to standard management and whose mother falls into a high-risk group.

A case of disseminated miliary tuberculosis in a five-year-old child.

A five-year old girl was referred, by the local area medical officer, as she had a positive Mantoux test and a chest x-ray consistent with miliary tuberculosis. She had initially been identified three months previously as a contact of a case of open pulmonary tuberculosis. A CT scan of the brain at the time of presentation showed multiple intracranial tuberculomae. A CT Brain scan three months into the treatment regime showed a significant reduction in the number and size of nodules indicating a favourable response to treatment. This case emphasises the importance of rapid tracing of paediatric tuberculosis contacts, if serious complications and their consequences are to be avoided.

[Congenital tuberculosis associated with maternal disseminated miliary tuberculosis]. / Tuberculosis congénita asociada con tuberculosis materna miliar diseminada.

Untreated tuberculosis during pregnancy presents a serious risk for transmission of disease to the newborn and can result in adverse perinatal and obstetrical outcomes. Tuberculosis during pregnancy and congenital tuberculosis are infrequent conditions and are difficult to diagnose due the non-specificity of the symptoms. A case report is presented of a woman who had no children previously with disseminated miliary tuberculosis. Tuberculosis symptoms appeared immediately after birth of the first child, with a clinical diagnosis on the second month after childbirth, whereupon the patient died. The son, a premature infant, showed disease symptoms from the first day, with primary pulmonary complex and persistent atelectasis due to bronchial obstruction. The obstruction was due to thoracic lymphadenitis and coinfection with cytomegalovirus. The infant received standard treatment and his condition improved.

A cluster of tuberculosis cases in a family.

A 40 year old Indian woman who had recently returned from a visit to India with her eldest son was diagnosed with miliary tuberculosis in January 1994. Contact tracing revealed that her three sons, aged 19, 21, and 22, all had BCG scars from vaccinations administered at birth in India and Heaf tests of grades 2-3. None of them was given chemoprophylaxis, although this was considered, as suggested by the guidelines then available (1990). About 18 months later, the eldest son was notified as a case of tuberculosis. The youngest son, who shared a room with the eldest, developed a right tuberculous pleural effusion over three years after his mother became ill. The 41 year old husband of the index case and their 21 year old son remain well at the time of this report and are being followed up. These cases highlight the importance of stringent follow up, contact tracing, good liaison between general practitioners and chest clinic staff, and chemoprophylaxis for the contacts of tuberculosis cases. Guidelines about the management of contacts of sputum positive cases over 16 years old need to be clarified. A history of a recent overseas trip should raise suspicions of infection with tuberculosis.

[Congenital miliary tuberculosis. Apropos of a case]. / Miliaire tuberculeuse congénitale. A propos d'un cas.

Congenital tuberculosis is an uncommon but probably underestimated disease. All cases occurring in developing countries are not published. Twenty-nine cases have been published in the English literature since 1980. The diagnosis of congenital tuberculosis is different from post-natal tuberculosis and is based on recently defined criteria: bacteriologically proven tuberculosis in a new-born associated with at least one of the following: specific hepatic granulomatosis, tuberculosis infection of the placenta or maternal genital tract, exclusion of possible post-natal transmission. We report a case of congenital tuberculosis to be added to the 29 preceding cases meeting current diagnostic criteria.

Perinatally acquired neonatal tuberculosis: report of two cases.

Perinatally acquired neonatal tuberculosis occurs rarely, is difficult to diagnose, may be the indicator of untreated tuberculosis in the mother, and could result in nosocomial transmission to neonatal patients, visitors to neonatal intensive care units, and health care workers. The disease may be more common in certain ethnic and social groups. Neonatal mortality approaches 30%. We report two cases with different outcomes. A neonate was treated for clinical miliary tuberculosis and survived; Mycobacterium tuberculosis was cultured from bronchoscopic washings, maternal genital fluids, and tissues. A second infant died at age 46 days, and autopsy disclosed miliary tuberculosis of lungs, mediastinal and mesenteric nodes, liver, spleen, and bone marrow. The lungs were most severely affected, but the placenta and central nervous system were not involved. The histopathology was not granulomatous. After the diagnosis in the infant, the mother was ascertained to have pulmonary and genital tuberculosis. Fetal and neonatal tuberculosis could be acquired transplacentally as prenatal tuberculous chorioamnionitis, perinatally through aspiration and ingestion of infected maternal genital tissues and fluid, or postnatally through droplet spread from cases of active tuberculosis. These two neonates probably acquired the disease perinatally from maternal genital tuberculosis.

Congenital tuberculosis localised to the ear.

We report two infants who had localised congenital tuberculous otitis. In both cases the infants presented with an ear discharge and both mothers had been diagnosed as having miliary tuberculosis. Infection is thought to have occurred in utero or during birth.

Congenital tuberculosis. Review and diagnostic guidelines.

A review of congenital tuberculosis was prompted by the successful treatment of this disease in a unique patient. She was followed up for 27 years, and gave birth to two normal, uninfected newborns despite calcifications throughout her abdomen and elsewhere. Tuberculosis of the newborn, whether acquired congenitally or postnatally, is preventable. Recommendations for diagnosis of congenital tuberculosis are given. Determination of the mother's tuberculin status or suitable testing should be done early in pregnancy. Endometritis is cited as an unrecognized source of fetal infection.