Author
Information
Iyer
SM*, Bhende AD*, Kher AR**.
(*
Ex.Specialist Medical Consultant,, ** Hon. Assistant Professor And HOD, Shri
Harilal Bhagwati Municipal General Hospital , Mumbai, India)
Abstract
Pregnancy is an
immunocompromised state and hence a pregnant woman is susceptible to
tuberculosis. Fever, weight loss and cough with
expectoration – the classical symptoms may not be present in all cases. We
present an unusual presentation of tuberculosis in pregnancy.
Introduction
Case
Report
A 30 year old
primigravida married since 2 years, with 16 weeks of gestation presented
with cough on and off since 1 month.
There was no expectoration, fever, weight loss or any other complaints. She
weighed 60 kg, was vitally stable; respiratory system was clear, and obstetric
findings were corresponding per abdomen. All routine investigations were normal.
She only had cough without expectoration starting at about 12-14 weeks. She was
given symptomatic treatment for the same. When the cough persisted, amoxicillin
was given for a week. However the cough persisted and so a pulmonologist’s
reference was taken. Her FEV was reduced. A differential diagnosis of gastric
reflux or cough variant asthma in pregnancy was kept. As there was no sputum
production, sputum examination was not possible. She was started on foracort
rotacaps, and tab esomeprazole. After 20 days of this therapy with not much
benefit, a chest radiograph was obtained, which showed a cavitatory lesion of
1.5x 1.5 cm in left upper zone of the lung. She was started on category 1
antituberculosis therapy (AKT). Nebulization with hypertonic saline was given
and then sputum collection was tried. Two of the 3 samples did not have sputum
and had saliva only. Sputum AFB was negative. Culture was done and line probe
assay showed 1-19 colonies of M. tuberculosis resistant to isoniazid but
sensitive to rifampicin. She showed drastic
improvement after starting AKT and the cough stopped within ten days. Four drug
AKT was continued and the patient was asymptomatic throughout the antenatal
period. A repeat chest radiograph after 2 months of therapy showed complete
resolution of the cavitatory lesion. She went into spontaneous labor and
delivered a female child of 2.54 kg by cesarean section for non progress of
labor. The baby was investigated for tuberculosis – USG abdomen was normal and
so was placental histopathology. Repeat chest radiograph at 6 months also
showed complete resolution of the lesion.
Figure 1. Chest
radiograph before treatment.
Figure 2. Chest
radiograph after treatment.
Discussion
Tuberculosis presents
similarly in pregnant and non pregnant[1] but diagnosis may be delayed by the
non-specific nature of symptoms[2] and the presence of fatigue and malaise in
pregnancy.[3] The most common site in pregnancy is pulmonary. Good et al
reported patients with culture positive disease-74% had cough, 41% had weight
loss, 30% had fever, malaise or fatigue, and 19% had hemoptysis; 20% had no
symptoms but all had abnormal X-Rays.[1] Moreover, women with tuberculosis in
pregnancy tend to postpone having chest radiography which complicates the
diagnosis even further.[2] . Chest radiography, which is a simple
investigation, does not carry much harm to the fetus and can help in the
diagnosis. Short course chemotherapy trials have shown that 6 month regimens of
rifampicin isoniazid, pyrazinamide and
ethambutol followed by 2 months rifampicin and isoniazid is the treatment of
choice for tuberculosis.[4,5] However drug resistance is becoming highly common
and the therapy has to individualized.
Maternal and fetal
outcomes in pregnancy vary with the site of the tuberculosis and the timing of
diagnosis in relation to delivery. In those with a late diagnosis, obstetric
morbidity is increased fourfold and preterm labor ninefold.[6] A higher
frequency of abortion, toxemia, and intrapartum complications have been reported.[7]
The fetus can only be infected in utero via the umbilical cord. This is however
very rare.
Conclusion
One should not ignore
cough in pregnancy and any cough lasting more than 2 weeks should be thoroughly
evaluated. Clinicians should remember that tuberculosis may be sputum negative
and may have atypical manifestations and that a negative sputum report only
gives a false sense of relief that all is well. However a simple investigation
like chest radiography will help in clinching the diagnosis. Early diagnosis
and prompt treatment can prevent maternal and perinatal morbidity and
mortality.
References
- Good JT, Iseman MD, Davidson PT, et al. Tuberculosis in association with pregnancy.Am J ObstetGynecol.1981; 140:492–498.
- Doveren RFC, Block R.Tuberculosis and pregnancy: a provincial study (1990–96). Neth J Med.1998; 52:100–106.
- Hamadeh MA, Glassroth J.Tuberculosis and pregnancy, Chest.1992; 101:1114–1120.
- Joint Tuberculosis Committee of the British Thoracic Society(1998) Chemotherapy and management of tuberculosis; recommendations 1998. Thorax.1998; 53:536–548.
- Figueroa-Damien R, Arredondo-Garcia JL. Pregnancy and tuberculosis: influence of treatment on perinatal outcome. Am J Perinatol .1998;15:303–306.
- Bjerkedal T, Bahna SL,Lehmann EH. Course and outcome of pregnancy in women with pulmonary tuberculosis. Scand J Respir Dis.1975; 56:245–250.
Iyer
SM, Bhende AD, Kher AR. JPGO 2015. Volume 3 No.
1. Available from: http://www.jpgo.org/2016/01/atypical-presentation-of-tuberculosis.html