Congenital TB

Congenital tuberculosis is defined as tuberculosis occurring in infants as a result of infection with Mycobacterium tuberculosis either during the intrauterine life or before complete passage through birth canal. It is a rare disease with a high mortality (50%). So far, Less than 300 cases of congenital tuberculosis have been reported. Mattai (1994) believes that the case is more than this but much larger number gone unreported or undiagnosed especially in developing country.

Three modes of infection have been proposed which are 1) Hematogenous infection via umbilical vein, hence primary complex lesion is in liver, 2) fetal aspiration of infected amniotic fluid and 3) fetal ingestion of infected amniotic fluid.

Clinical features is often non specific but few features has being observed which are premature born baby, respiratory distress, lethargy, poor feeding, fever, Irritability, abdominal distension, failure to thrive, hepatosplenomegally, lymphadenopathy, otitis media with or without mastoiditis, obstructive jaundice due to glands in the porta hepatis and papular or pustular skin lesions.

Bushra Babar [2005] also add that there should be high index of suspicion of congenital tuberculosis in a neonate with sepsis-like presentation, non-resolving pneumonia or unexplained illness

An attempt to describe the criteria of congenital tuberculosis was made by Beitzki in the year of 1935. The criteria includes 1) Isolation of M. tuberculosis from the infants, 2) Demonstration of the primary complex in the liver and 3) In the absence of primary complex in the liver, there is either a) Evidence of tuberculosis within days after birth, b) Absence of contact with a case of tuberculosis after birth.

A year later, Cantwell's made a modification to Beintzki criteria. According to his criteria, diagnosis can be made based on proven tubercular infection plus either one of this criteria 1) Lesion in the first week of life, 2) Ceseating hepatic granuloma, 3) Maternal endometrial or placental TB and 4) Exclusion of tubercular infection in all contacts.

Mantoux test frequently negatives in most patient. In a study conducted by Hageman et al. Only 2 of the 14 infants with congenital TB had positive tuberculin tests. Another study shows only two out of nine infants have positive reaction with Mantoux test. [G. Hassan]

According to Neyaz Z, chest X-ray may show normal finding especially in early course of disease. Later changes may show multiple pulmonary nodules, hilar and mediastinal adenopathy, necrotic mediastinal nodes, consolidation with cavitation and extensive bronchopneumonia, miliary or interstitial pattern in cases with hematogenous spread, or patchy bronchopneumonia to diffuse air space disease in infections acquired due to aspiration of infected material.

Abdominal Ultrasound is major diagnostic tool for congenital tuberculosis as it is simple to performed, low cost and widely available. Findings may include hepatomegally, splenomegally, hepatosplenomegally or multiple hypoechoiec hepatic and splenic foci

In addition to abdominal ultrasound, Percutaneous liver biopsy may also be performed and revealed ceseating hepatic granuloma or scattered miliary granuloma in portal area and hepatic lobule [Naiyereh Najati]

Other useful investigation may include lumbar puncture and gastric aspiration for AFB.

Transmission to other patient and health care worker is rare as it is not associated with cavitary lesion or extensive infiltrates and infant is unable to forcefully expectorate and harbor smaller amount of bacilli in their secretion

Congenital tuberculosis may be complicated with meningitis, miliary tuberculosis and otitis media that may result to seizure, deafness and death especially if there is a delay in diagnosis.

The prognosis is depends on early recognition and treatment. Previously, it is nearly uniformly fatal. However, in the era of isoniazid, fatal outcome is 45%. Most of the death is caused by delays in diagnosis and treatment.

References

1. Brent W. Laartz, Hugo J. Narvarte, Douglas Holt et alm "Congenital Tuberculosis and Management of Exposures In A Neonatal Intensive Care Unit", Infection Control And Hospital Epidemiology, Vol. 23 No. 10:573-579 (2002)

2. Bushra Babar, Nazar Ullah Raja, Ejaz A. Khan et al, "Congenital tuberculosis revisited - A case report and recent review of literature", Infectious Diseases Journal of Pakistan, July – Sept 2005:89-92

3. Dharmendra Singh, Sangram Singh, Sanjay B. Raut et al "Isolated liver tuberculosis: a case report", Pediatr Surg Int (2004) 20: 727–728, Springer-Verlag

4. Flor M. Muñoz, MD; Lydia T. Ong, PAC; Diane Seavy, RN et al, "Tuberculosis among Adult Visitors of Children with Suspected Tuberculosis and Employees at a Children’s Hospital", Infection Control and Hospital Epidemiology Vol. 23 No. 10:568-572, 2002

5. G. Hassan, Waseem Qureshi and SM Kadri, "Congenital Tuberculosis", JK Science, Vol. 8 No. 4, October-December 2006

6. John Matthai, V.R. Ravikumar & M. Ramasamy "Congenital Tuberculosis : Under Diagnosed or Under Reported?", The Indian Journal of Pediatrics vol 61, No 4, 1994

7. Naiyereh Najati& Mandana Rafeey, " Congenital Tuberculosis Proven by Liver and Lymph Node Biopsy", Research Journal of Biological Sciences 3(3):329-331, Medwell Journals 2008

8. Neyaz Z, Gadodia A, Gamanagatti S, Sarthi M, "Imaging findings of congenital tuberculosis in three infants", Singapore Med J 2008; 49(2) : e44

9. S.B. Grover, D.K. Taneja, A. Bhatia et al "Sonographic diagnosis of congenital tuberculosis: an experience with four cases", Abdominal Imaging 25:622-626 (2000), Springer-Verlag New York Inc