A70-37 Breathless and Expecting: When Tuberculosis Mimics Pregnancy Changes

Abstract Introduction Tuberculosis (TB) can be a challenging diagnosis in pregnancy as symptoms often overlap with normal pregnancy changes. Identifying risk factors can aid in timely diagnosis to initiate treatment and reduce mortality. Case summary A 40-year-old G2P0202 female from Mexico with juvenile rheumatoid arthritis (JRA) on TNF alpha inhibitor (TNFi - golimumab 2000-2023, certolizumab 2024 - 2025) presented at 32 weeks gestation with several weeks of abdominal pain, shortness of breath, and admitted for concern for preeclampsia. QuantiFERON Gold was negative prior to starting TNFi. On admission, patient was febrile and tachycardic but saturating well on room air. She subsequently developed shortness of breath and chest pain for which CT pulmonary angiography was obtained, showing right upper lobe mass with mediastinal lymphadenopathy, innumerable pulmonary nodules bilaterally, and splenic lesions. Pulmonary nodules followed a lymphogenic and hematogenic spread, concerning for metastatic disease. Later Mycobacterium Tuberculosis (MTB) PCR and Acid-Fast Bacillus (AFB) sputum were positive, with cultures growing pansensitive MTB, confirming disseminated tuberculosis. Brain MRI without contrast demonstrated several brain lesions, including one in central pons, concerning for tuberculoma. Lumbar puncture was not consistent with TB meningitis (white blood count 2, glucose 47, protein 33). She was started on rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) with dexamethasone given concern for brain involvement. On hospital day fifteen, she underwent an urgent cesarean section for chorioamnionitis and fetal intolerance of labor. Baby was admitted to the neonatal intensive care unit, and workup for congenital TB was negative. Patient’s symptoms and radiographic abnormalities improved on RIPE and was discharged home with Public Health follow up. Discussion Significant risk factors for disseminated tuberculous disease in pregnant individuals include human immunodeficiency virus (HIV) infection, immigration from high-burden regions, immunosuppression, and delayed diagnosis due to symptom overlap with pregnancy. Additionally treatment with TNFi disrupts granuloma formation, which impairs containment of latent and new TB infection. This patient had multiple risk factors prompting a TB screen upon admission. Corticosteroid use is strongly recommended for tuberculosis brain lesions when there is tuberculous meningitis because it reduces inflammation and improves neurologic outcomes. Evidence is less robust for CNS involvement/tuberculoma without meningitis. Steroids were started for our patient given the critical location of the lesion and the risk of edema/inflammation with anti-TB therapy. In conclusion, there should be a high index of suspicion for TB among high-risk pregnant individuals with prompt treatment initiation to prevent adverse maternal and fetal outcomes. This abstract is funded by: None