CASE REPORT

Disseminated congenital tuberculosis presenting as peritonitisin an infant

Mi Hyun Lee • Gye-Yeon Lim • Jae Hee Chung •

So-Young Kim

Received: 18 September 2012 / Accepted: 11 December 2012 / Published online: 12 January 2013

� Japan Radiological Society 2012

Abstract Congenital tuberculosis is a rare disease which

is curable after early diagnosis. Making an early diagnosis

of tuberculosis in an infant is difficult, however, because of

its nonspecific clinical findings. It therefore requires a high

index of suspicion. In this paper we report the case of an

infant with disseminated congenital tuberculosis involving

the chest, liver, spleen, abdominal lymph nodes, mesentery,

and peritoneum, and which presented as chylous ascites

with peritonitis.

Keywords Congenital tuberculosis � Tuberculosis �Ascites � Infant

Introduction

Congenital tuberculosis is a rare disease; to date, approx-

imately 300 cases have been reported in the world literature

[1]. Tubercular infection during fetal life may occur from

an infected placenta through the umbilical vein, forming a

primary complex in the liver. Alternatively, fetal ingestion

or aspiration of infected amniotic fluid may result in a

primary complex in the gastrointestinal tract or the lungs,

respectively [1]. Early diagnosis of congenital tuberculosis

is important because the outcome is invariably poor in the

absence of early institution of anti-tuberculous therapy.

Symptoms and clinical findings of congenital tuberculosis,

for example respiratory distress and fever, are nonspecific

and may be present in bacterial sepsis and in other con-

genital infections and can lead to misdiagnosis of neonatal

pneumonia or sepsis. Because early diagnosis and timely

treatment depend on a high index of suspicion, familiarity

with both the common and uncommon manifestations of

congenital tuberculosis is required of physicians. We report

a case of disseminated congenital tuberculosis involving

the chest and abdomen which presented as peritonitis in a

three-week-old neonate. We wish to emphasize the ultra-

sonography (US) and whole-body magnetic resonance

imaging (MRI) findings.

Case report

A 19-day-old, male infant was referred to our hospital with

a one-week history of a low-grade fever and abdominal

distention. The infant was delivered by Caesarean delivery

at 41 ? 1 weeks and had a birth weight of 3.55 kg. The

immediate neonatal period was uneventful. At the time of

delivery the mother’s past history of tuberculosis was

unknown.

On physical examination, the infant’s respiratory rate

was 44/min and his body temperature was 38.6 �C. His

abdominal circumference was 44.5 cm. There was no

cyanosis, jaundice, or significant lymphadenopathy. Lab-

oratory studies revealed a decreased WBC count of

4670/mm3, a platelet count of 49000/mm3, and increased

C-reactive protein of 9.93 mg/L. These findings increased

the possibility of sepsis. The patient’s liver function tests

M. H. Lee � G.-Y. Lim (&)

Department of Radiology, St. Mary’s Hospital, The Catholic

University of Korea, #62, Yeouido-dong, Yongdungpo-gu,

Seoul 150-713, Korea

e-mail: shlgy@catholic.ac.kr

J. H. Chung

Department of Surgery, St. Mary’s Hospital,

The Catholic University of Korea, Seoul, Korea

S.-Y. Kim

Department of Pediatrics, St. Mary’s Hospital,

The Catholic University of Korea, Seoul, Korea

123

Jpn J Radiol (2013) 31:282–285

DOI 10.1007/s11604-012-0174-4

were normal. The Mantoux test was positive, resulting in

an induration of 10 mm at 48 h.

A radiograph obtained on the day of the patient’s

referral revealed centralization of bowel loops with lateral

abdominal bulging and patchy lesions in the right parahilar

and left apical regions (Fig. 1). Abdominal US revealed

multiple, hypoechoic foci in the liver and spleen, con-

glomerated hypoechoic lymph nodes in the porta hepatis or

hepatic hilum region, and a large amount of ascites con-

taining debris with fluid–fluid level (Fig. 2). Contrast-

enhanced, whole body MRI confirmed the US findings and

also revealed pronounced enhancement of thickened peri-

toneum, mesenteric leaves, bowel wall, and omentum

(Fig. 3). Necrotic lymph nodes in the porta hepatis region

and in the subcarinal region of the mediastinum showed

peripheral enhancement with central low signal intensity

(Fig. 3). No definite brain abnormality was noted on either

the US or the whole-body MRI.

Analysis of the ascites fluid revealed a white blood cell

count of 360/mm3 with 63 % lymphocytes, a triglyceride

level of 459 mg/dL, a total cholesterol level of 69 mg/dL,

total protein level of 2.9 mg/dL, and an adenosine deami-

nase level of 42.6 IU/L. These results suggested the pres-

ence of chyle. No organisms were detected in the smears or

cultures obtained from the ascitic fluid. Specimens obtained

from blood, urine, gastric aspirate, and cerebrospinal fluid

to assess the presence of acid-fast bacilli (AFB), were

negative and no growth of any organism was found.

Sputum culture was positive for AFB. Laparoscopic

omentum biopsy revealed caseous granulomatous inflam-

mation and multinucleated giant cells. The infant’s mother

declined endometrial biopsy and examination for AFB. The

infant was started on anti-tuberculosis drugs, and his clinical

condition improved. Calcifications in the liver and spleen

and lymphadenopathy were noted on follow-up US obtained

7 weeks after treatment, and increased calcific changes of

lesions were noted on serial follow-up US (Fig. 4).

Fig. 1 Radiograph of a three-week-old infant shows centralization of

bowel loops with lateral abdominal bulging and patchy lesions in the

right parahilar and left apical lung regions

Fig. 2 a Longitudinal sonogram of the left upper quadrant shows

multiple, hypoechoic foci in the spleen. b Axial sonogram of the liver

shows conglomerated, hypoechoic lymph nodes in the porta hepatis or

hepatic hilum region (arrows). c Axial sonogram of the right lower

quadrant shows a large amount of ascites containing fluid–fluid level

(arrows)

Jpn J Radiol (2013) 31:282–285 283

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Discussion

Congenital tuberculosis is thought to be transplacentally

transferred to the fetus from the infected mother, after

which it forms a primary complex in the infant’s liver and

has secondary hematogenous spread; it can also occur as a

result of aspiration or ingestion of infected amniotic fluid

which becomes primarily focused in the infant’s lung or

gastrointestinal tract [2–5]. The established diagnostic cri-

teria for congenital tuberculosis [2] include proven tuber-

culosis lesions in an infant and at least one of the following:

– lesions occurring during the first week of life;

– the existence of primary hepatic complex;

– maternal genital tract or placental tuberculosis; or

– exclusion of postnatal transmission by thorough inves-

tigation of contacts.

For our patient there was no investigation of tuberculous

infection of the maternal genital tract or placenta, although

other criteria, for example primary involvement of the liver

and exclusion of the possibility of postnatal transmission

by hospital attendants or other family members, should be

considered to enable correct diagnosis of congenital

tuberculosis. The modes of presentation, treatment, and

immediate prognosis of tuberculosis do not differ signifi-

cantly between that seen in congenital infection and that in

early, post-natally acquired tuberculosis [4–6].

Fig. 3 Contrast–enhanced, whole-body MRI obtained during the

third week of the infant’s life. Axial T1-W (a), T2-W (b), and

enhanced T1-W (c) MR images of the abdomen show multiple,

conglomerated, enlarged lymph nodes in the porta hepatis region

(arrows) with peripheral rim enhancement. Multiple, tiny, low-signal-

intensity nodular lesions were scattered throughout the spleen

(c, arrowheads). Coronal T1-W (d) and enhanced T1-W

(e, f) images of the chest and abdomen show large amount of ascitic

fluid and marked thickening with enhancement of the peritoneum

(arrows). Tiny, low-signal-intensity nodular lesions were scattered in

the liver and spleen (e, f, arrowheads). Necrotic lymph nodes with

rim enhancement are also noted in the subcarinal region of the

mediastinum (f, arrow)

Fig. 4 Follow-up abdominal US obtained 13 weeks after treatment

shows calcifications within multiple foci of the spleen

284 Jpn J Radiol (2013) 31:282–285

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The liver and lung are the two most commonly involved

sites of congenital tuberculosis. Frequently reported

imaging findings include multiple pulmonary nodules,

necrotic mediastinal lymphadenopathy, parenchymal infil-

tration, hepatosplenomegaly, and multiple focal lesions in

the liver and spleen [4, 6, 7]. Early in the course of the

disease, chest radiographs may be normal, with profound

radiological abnormalities only developing later [4, 6, 7].

In our patient, no definite abnormality was detected on the

initial chest radiograph, although necrotic mediastinal

adenopathy was noted on whole-body MRI scanning per-

formed at the same time.

To the best of our knowledge, there are only a few case

reports describing congenital tuberculosis presenting as

ascites [5, 7, 8]. According to one report which analyzed

170 cases of congenital tuberculosis, only 10.5 % of the

patients had ascites [7]. These patients eventually devel-

oped abdominal distension with low-grade fever mani-

fested by peritonitis with chylous ascites. Tuberculous

chylous ascites is rare and, when present, fluid–fluid level

or debris can be seen on US, as in our patient. Although

tuberculous involvement limited to the peritoneum is rare,

peritoneal involvement is seen in association with wide-

spread abdominal disease. Involvement of the peritoneal

cavity, mesentery, and omentum seems to occur because of

rupture of mesenteric lymph nodes, presence of the primary

complex of tuberculosis just beneath the spleen or liver

surface, or serosal continuity from adjacent structures. In

our case, enhanced, whole-body MRI revealed extensive

tuberculous peritonitis appearing as enhanced thickening of

the peritoneum and mesentery, matted bowel loops, a

smudged pattern of the omentum, and a large amount of

viscous ascitic fluid.

Because early diagnosis of congenital tuberculosis

requires a high index of suspicion, imaging is essential to

ensure correct diagnosis. This disease is usually evaluated

by using chest radiographs, US, and CT. To evaluate chest

lesions, CT is useful for identifying parenchymal lesions

and lymphadenopathy, because it is superior to radiography

and capable of earlier detection than radiography [6].

Because US does not involve a risk of exposure to ionizing

radiation, it is a very useful imaging modality for detecting

abdominal abnormalities, not only for early lesion dem-

onstration but also for confirmation of lesion etiology by

guided biopsy. However, US is generally used for regional

evaluation rather than to evaluate the entire extent of dis-

ease. Congenital tuberculosis is frequently disseminated

throughout the body. In addition, as in this case, evaluation

for necrotic adenopathy and peritoneal involvement of

congenital tuberculosis requires contrast-enhanced

examinations. However, contrast-enhanced CT is not

desirable in infants because it delivers a significant radia-

tion dose. Contrast–enhanced, whole body MRI enables

acquisition of images of the entire body in a matter of

minutes and without exposure to ionizing radiation. As

intravenous contrast agents are not used in routine, whole-

body MR examinations, we perform contrast examinations

for this reason. Whole-body MRI is thought to have rela-

tively poor ability to detect lung lesions or small lymph

nodes, although we had no difficulty using this modality to

detect mediastinal nodes and the presence of abdominal

involvement. To the best of our knowledge, whole-body

MRI can be successfully used as a supplemental diagnostic

method followed by sonography to assess the extent of

disease in infants with congenital tuberculosis.

In this case, calcifications in the liver and spleen and

lymphadenopathy were noted on follow-up US after ther-

apy had been started. Serial US can also be used as a

follow-up modality for lesions, and for monitoring calci-

fications seen as part of the healing process in patients with

congenital tuberculosis.

Although congenital tuberculosis is a rare disease, it

should be included in the differential diagnosis for infants

who have extensive peritoneal involvement and wide-

spread abdominal disease.

Conflict of interest The authors declare that we have no conflict of

interest.

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