Perinatal or congenitally acquired tuberculosis is probably under-recognized because hard to diagnose.1–3
CASE HISTORY
At the age of 52 days a baby was brought to our hospital because of failure to thrive and cough and breathlessness which had started at 25 days of life and become increasingly severe. He had been born normally at full term. For the past three months the mother had been on treatment for fibroexudative pulmonary tuberculosis but she had been sputum-negative at the time of delivery. The family were from the `Gujjar' community.
On examination, the baby's temperature was 39°C. His weight was 4 kg (10th percentile) and his length was 60 cm (75th percentile). There were bilateral diffuse crepitations and rhonchi in the chest. the chest radiograph showed a thick-walled cavity in the mid zone of the right lung (Figure 1) and Mycobacterium tuberculosis was present in gastric aspirate. Cutaneous tubercular testing caused induration of 20 mm after 72 h; cerebrospinal fluid was normal and blood chemistry revealed no abnormality. Cavitatory pulmonary tuberculosis was diagnosed and the baby was put on oral isoniazid 10 mg/kg, rifampicin 10 mg/kg and pyrizinamide 20 mg/kg daily. The pyrizinamide was stopped two months later. After four months' treatment the baby had improved clinically and radiographically.
Figure 1.
Chest radiograph showing thick-walled cavity in right mid zone
COMMENT
The incidence of childhood tuberculosis in Kashmir is high, especially in certain ethnic groups including `Gujjars'. In a short study conducted in our hospital, the disease accounted for 3% of all deaths.4 Diagnosis in infancy presents special difficulties, and these are compounded in our valley by lack of diagnostic infrastructure in the peripheral hospitals. Also, through poverty and ignorance, the babies and infants tend not to arrive until gravely ill. In the present case, despite the positive history in the mother, tuberculosis was not suspected at first and the baby was given antibiotics.
A similar sequence has been reported by Chou.5 Was the infection congenital or acquired perinatally? Both can present with bronchopneumonia, miliary mottling, upper and mid zone pneumonia, interlobulitis, or reticulonodular infiltrations2,3,6–8 but congenital infections tend to be diffuse rather than localized. In this case the apparent absence of extrapulmonary disease makes us think that the infection was acquired at or near the time of birth, but though the presence of cavitatory pulmonary tuberculosis at only 52 days is remarkable. One way to assess the source and timing of infection is endometrial biopsy in the mother.8 A positive biopsy soon after the birth would have called for immediate treatment of the baby.
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