Neonatal Disseminated Tuberculosis With Genitourinary Involvement

To the Editors: Mycobacterium tuberculosis (MTB) involving the renal system is rare in children.1 Alexander and Carol reported a 5-month-old with renal and miliary tuberculosis (TB) in 2009. Lattimer et al.2 in their case series found 2–3 years as the earliest stage of presentation of renal TB. Herein, we report a case of an infant with disseminated tuberculosis affecting the genitourinary system. A 58-day-old male infant, presented to us with fever, cough and increased respiratory activity for 3 days. He weighed 2.3 kg at birth, received the Bacillus Calmette–Guérin vaccine at birth, and had been exclusively breastfed since then. On presentation to us, weight was 1.9 kg and there was anasarca, tachycardia, respiratory distress and hypoxemia with decreased air entry. Chest radiograph showed homogenous opacification of the right upper, middle and lower zones with a mediastinal shift to the left (Fig. 1). Blood investigation revealed hemoglobin 8.2 g/dL, white blood cell count of 19,100/mm³, platelet counts 188 × 10³/µL, with raised alanine transaminase, and aspartate transaminase, arterial blood gas showed metabolic acidosis. He was started on intravenous amikacin, piperacillin–tazobactum for sepsis and required mechanical ventilation. Endotracheal tube secretions were positive for rifampicin-sensitive MTB by the GeneXpert MTB/Rif assay. Antimicrobials were changed to amikacin, ethambutol and meropenem-amoxicillin-clavulanate to cover MTB in view of elevated transaminases and the presence of sepsis. On day 7, the baby developed polyuria. Ultrasonography abdomen revealed bilaterally hyperechogenic kidneys with ascites. A urine sample was tested using the Xpert MTB ultra/Rif assay which tested positive for rifampicin-sensitive MTB. A final diagnosis of disseminated TB with genitourinary involvement was made. The same therapy was continued, however, he succumbed to illness on day 16th due to respiratory failure. The father was subsequently diagnosed to have miliary TB and the mother was hospitalized with ascites.FIGURE 1.: Chest radiograph showing homogenous opacification of the right upper middle and lower zones with a shift of the mediastinum to the left.TB in pregnancy can be transmitted to the fetus either through hematogenous spread via the umbilical vein from the placenta, forming a primary complex in the lung or liver, or infected amniotic fluid from the placenta or genital tract, ingestion or aspiration of this infected amniotic fluid leads to the development of a primary complex in the lungs or gastrointestinal tract. TB may be contracted in the postnatal period by inhalation of bacilli or ingesting infected breast milk.3 Cantwell’s diagnostic criteria for congenital TB include proven tuberculous lesions plus one of the following: (1) Presence of a tuberculous lesion in the first week of life, (2) Primary hepatic granulomas (caseating), (3) Genital tract TB or placental TB in the mother and (4) thorough investigation of contacts to exclude postnatal transmission.3 In our patient, we could not prove that the child had congenitally acquired TB as the mother was not tested and the child had presented after 3rd week of life. However, the presence of miliary TB in the father and ascites in the mother suggests that the child may have been exposed to TB from the parents. The final diagnosis of our patient was based on the Xpert MTB/Rif assay diagnosed pulmonary disseminated TB and Xpert MTB ultra/Rif assay diagnosed the genitourinary involvement. There are no specific treatment guidelines for perinatal tuberculosis in National TB Elimination Programme. American Academy of Pediatrics recommendation includes a 4-drug regimen for the first 2 months (intensive phase)—isoniazid (INH), rifampin (RIF), pyrazinamide and either ethambutol or an aminoglycoside such as amikacin. After the intensive phase, INH and RIF therapy is the drug regimen recommended for the continuation phase of 7–10 months. The total duration of treatment is usually 9–12 months.4 In our patient, due to raised transaminases, INH, RIF and pyrazinamide could not be given. Thus, either ethambutol and amikacin were the better choice. Meropenem-amoxicillin was added to cover both MTB and probable sepsis.