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Tuberculosis in Infants Less Than 3 Months Ofage

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Tuberculosis in Infants Less Than 3 Months Ofage Archives of Disease in Childhood 1993; 69: 371-374 371 Tuberculosis in infants less than 3 months of age Arch Dis Child: first published as 10.1136/adc.69.3.371 on 1 September 1993. Downloaded from H S Schaaf, R P Gie, N Beyers, N Smuts, P R Donald Abstract identified from a register of cases proved by The clinical and radiological features in 38 culture. infants less than 3 months of age with A history of contact with adult pulmonary tuberculosis proved by culture are tuberculosis, the presenting symptoms and described and may aid early diagnosis of their duration, and clinical features such as this often fatal condition. Respiratory lymphadenopathy, respiratory signs, and the symptoms, cough in 33 (87%) and tachyp- presence of hepatosplenomegaly were noted. noea in 31 (82%), were the commonest Tuberculin testing was either by Mantoux test presenting symptoms. Twenty five infants 5 units purified protein derivative or Tine test (66%) had hepatomegaly and 20 (53%) (Lederle) with an induration of > 15 mm or a splenomegaly. Mantoux testing gave an confluent reaction respectively being regarded induration of >15 mm in three of 17 (18%) as significant. infants. In a further five a Tine test gave The chest radiographs of 27 (71%) of the 38 confluent response. Chest radiography in infants were assessed systematically by a panel 27 infants showed miliary tuberculosis in consisting of all the authors. Particular seven (26%) and hilar or paratracheal attention was paid to the presence of miliary adenopathy in 14 (52%) and 10 (37%) tuberculosis, the presence of hilar or para- respectively. Compression of either the tracheal adenopathy, narrowing of large bronchi or trachea or both was noted in 15 airways, and signs of air trapping. In a further (56%). Detection of this complication was nine children a radiologist's report was aided by high kilovolt radiographs. A available. In eight infants, in whom narrowing culture of Mycobacterium tuberculosis of the large airways was clinically suspected, was obtained from gastric aspirate in 35 high kilovolt chest radiographs were taken. Six (92%) infants, but positive cultures were of the infants who presented during the also obtained from cerebrospinal fluid, neonatal period have been briefly reported tracheal or bronchial aspirate and liver previously.7 8 and lymph node biopsy. Of 30 mothers The study was approved by the ethical evaluated seven (23) had previously committee of the Faculty of Medicine of the unsuspected pulmonary tuberculosis. University of Stellenbosch. (Arch Dis Child 1993; 69: 371-374) http://adc.bmj.com/ Results The morbidity and mortality of tuberculosis in The median age at presentation was 65 days childhood is at its highest in infancy and the with the youngest child being 8 days. The male frequent occurrence of disseminated forms of to female ratio was 24:14. The median tuberculosis such as miliary tuberculosis and duration of symptoms before the diagnosis of tuberculous meningitis is partly responsible for tuberculosis was considered and anti- this poor prognosis.' Furthermore many case tuberculous treatment started was 14 days on October 1, 2021 by guest. Protected copyright. reports emphasise the sometimes atypical (range 1-60 days). The duration of symptoms presentation of tuberculosis in infancy, so that were less than one week in 13 (34%) of the whether of congenital or postnatal origin, infants. diagnostic delay contributes to the poor Certain presenting features are summarised outcome.2-5 in table 1. The weight of 15 (42%) of the In this study we describe the clinical and infants was below the third centile. radiological features of tuberculosis proved by Tachypnoea (respiratory rate >50/min) was Tygerberg Hospital, culture presenting in 38 children at an age of present in 31 of the University of (82%) infants. Stellenbosch, less than 3 months and stress those features Tuberculous meningitis was clinically sus- Department of that may aid early diagnosis and treatment. pected in four infants and was confirmed by Paediatrics and Child special Health investigations. Mycobacterium tuber- H S Schaaf culosis was cultured from the cerebrospinal R P Gie Patients and methods fluid in two, one had miliary tuberculosis N Beyers This study was carried out in the paediatric involving the meninges demonstrated on post- P R Donald wards and outpatient department ofTygerberg mortem examination, and in one infant with Department of Hospital, a tertiary care hospital situated in the disseminated tuberculosis, computed tomo- Radiology south western Cape Province of South Africa, graphy showed hydrocephalus and a basal N Smuts an area with a particularly high incidence of exudate typical of tuberculous meningitis.9 Correspondence to: tuberculosis (>600/100 000 in 1990).6 Nine A tuberculin test was done and read in 31 Dr H S Schaaf, Department of Paediatrics and Child infants were identified during a prospective infants and was significant in eight (26%). Health, University of evaluation of childhood tuberculosis under- A Mantoux test resulted in an induration Stellenbosch, PO Box 19063, Tygerberg 7505, taken during 1991, and a further 29 infants less > 15 mm in three of 17 infants and a Tine test Republic of South Africa. than 3 months of age with tuberculosis proved gave a confluent reaction in a further five Accepted 28 May 1993 by culture seen between 1987 and 1990 were infants. 372 Schaaf, Gie, Beyers, Smuts, Donald The findings of the 27 chest radiographs available for evaluation by the authors are set Arch Dis Child: first published as 10.1136/adc.69.3.371 on 1 September 1993. Downloaded from out in table 2. A miliary picture was present in seven (26%) and signs of large airway compression in 11 (4 1%). In eight infants high kilovolt chest radiographs were also taken and revealed airway compression in a further four infants. Thus of the 27 infants, 15 7roo (56%) had compression of the large airways (figs 1 and 2). All nine chest radiographs, for which only a radiologist's report was available, showed some form of opacification either Table 1 Presentingfeatures in 38 infants less than 3 months ofage with culture proved tuberculosis; values are number (%o) History Household contact with adult pulmonary tuberculosis 19 (50) Cough 33 (87) 2 kilovolt a 2 Wheezing 15 (40) Figure High chest radiograph of month old Respiratory signs infant shows narrowing oflarge airways (arrow) in the Tachypnoea* 31 (82) absence ofobvious lymphadenopathy. Mantoux test was Stridor 6 (16) 17 mm indurated and a gastric aspirate culture positive for Wheeze 13 (34) M tuberculosis. Crepitations 17 (45) Bronchial breathing 2 (5) Other signs Weight <3rd centile for aget 15 (42) Hepatomegaly 25 (66) bronchopneumonic or lobar. Three were Splenomegaly 20 (53) reported to show miliary tuberculosis, four Prolonged jaundice 3 (8) Tuberculous meningitis 4 (11) lymphadenopathy (two paratracheal and two Extrapulmonary lymphadenopathy 3 (8) parahilar), and one bronchial compression. Sources ofpositive cultures for M tuberculosis *Respiratory rate >50 per minute. tWeight available in 36 infants. are listed in table 3. M tuberculosis was cultured from the gastric aspirate of 35 of the 38 babies. Other sources of positive cultures included Table 2 Findings on routine chest radiography of27 cerebrospinal fluid, liver biopsy, and tracheal infants less than 3 months of age with proved tuberculosis*; values are number (%o) and bronchial aspirates. Because of suspicion of tuberculosis in the Miliary tuberculosis 7 (26) infants, 30 of the mothers were evaluated for Lymphadenopathy Hilar 14 (52) active tuberculosis. In seven mothers (23%) Paratracheal 10 (37) previously unsuspected pulmonary tuberculosis http://adc.bmj.com/ Large airway compression Bronchial 11 (41) was diagnosed on chest radiography and Tracheal 2 (7) confirmed by sputum culture of M tuberculosis. Airtrapping 15 (56) Lobar consolidation 14 (52) A further four also had active pulmonary Bronchopneumonia 5 (19) tuberculosis confirmed by sputum culture ofM Ghon's focus 2 (7) Lobar collapse 4 (15) tuberculosis but the diagnosis had been made Pleural effusion 2 (7) previously. In addition one mother whose chest Normal radiograph 1 (4) radiograph was clear was only subsequently on October 1, 2021 by guest. Protected copyright. *Most infants had more than one abnormal finding on chest found to have urogenital tuberculosis. radiography. It is difficult and perhaps no longer of practical importance to apply Beitzke's criteria for congenital tuberculosis as the majority of infants survived and were not separated from their mothers at birth.3 However, taking into consideration maternal urogenital tuberculosis without pulmonary involvement, an absence of other close contacts for Table 3 Origin ofcultures positive for M tuberculosis in infants less than 3 months ofage Orzgsn ofculture positive No of for M tuberculosis infants GA only 28 GA+CSF 2 GA+tracheal or bronchial aspirate 2 GA+biopsy (lymph node/bone marrow) 2 GA+liver biopsy +bronchial aspirate Liver biopsy CSF+ bronchial aspirate l Tracheal aspirate 1 Figure 1 Chest radiograph of a 2-5 month old infant w bronchopneumonia, airtrapping, narrowing oflarge Total infants 38 airways (arrow), and right hilar lymphadenopathy. Total positive cultures 47 Mantoux test was 8 mm indurated and gastric aspirates were culture positive for M tuberculosis. CSF = cerebrospinal fluid, GA = gastric aspirate. Tuberculosis in infants less than 3 months ofage 373 pulmonary tuberculosis, an age at presentation months, but our experience illustrates that of less than 4 weeks and prolonged neonatal should infection take place at a very young age jaundice as a presenting symptom, only seven that tuberculous meningitis may be seen in Arch Dis Child: first published as 10.1136/adc.69.3.371 on 1 September 1993. Downloaded from infants can confidently be said to have had infants less than 3 months of age not only congenital tuberculosis. as a serous reaction complicating miliary HIV infection has only recently been tuberculosis but in its classical form with detected in the western Cape Province and in a hydrocephalus accompanied by a basal 1991 survey the prevalence rate in women exudate.
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