Tuberculoza neonatala

7/28/2019 Tuberculoza neonatala

1/24

NEWBORN WITH

ACUTE RESPIRATORY FAILURE

P. Avram1, M.Craiu1, A.V.Cochino1, D. Mihailescu2

1- Institute for Mother and Child Care, Bucharest,

2 - M.Nasta Pulmonology Institute, Bucharest, Romania


2/24

HISTORY

3 weeks old, female

PERSONAL HISTORY:

G 2, P2, Uneventful pregnancy Vaginal delivery

Birth weight=2550g, preterm baby (GA=34 weeks),

No mechanical ventilation in nursery

Apgar Score 9 /5 min


3/24

HISTORY OF THE PRESENT

ILLNESS (1)

4 days history of:

unproductive and rare cough

Respiratory distress


4/24


ILLNESS (2)

No respiratory disease contact (affirmative)

Healthy parents (affirmative)

Mother - smoker

BCG vaccinated


5/24


ILLNESS (3)

No fever

No nasal obstruction

Normal appetite, no vomiting

Normal reactivity

No other simptoms till 4 days before admission


6/24

PHYSICAL EXAMINATION

No fever, G=2580g (


7/24

1ST ADMISSION - JUNE 2006

ABG (capillary!):

pCO2=47.9 mmHg

pO2=34.8 mmHg

BE=1.2 mmol/l

HCO3=27.3 mmol/l

Serum

electrolytes:

Na=125 mEq/l

K=5.89 mEq/l

Ca=1.24 mEql/l

WBC=22.400/mm3

Ly=17.9%

Mo=4.9%

ESR=17mm/h

CRP=7.7 mg/dl

(N


8/24

X-ray 1 (day 2)

AFTER 2 DAYS:

-severe respiratory distress

-crackles (left posterior)

-HR=140/min-lethargy, hypertonia

CSF:Pandy neg

7elem/mm3

Glucose=0.42 g/l

Cl-=6.66 g/l

protein=0.65 g/l

Endotracheal fluid:smear: no Pn.carinii

culture: Klebsiella oxytoca

HIV= NEGATIVE

Blood culture=negative


9/24

X-ray 2 (day 3)DG : BRONCHOPNEUMONIA

WITH KLEBSIELLA OXYTOCA

Orotracheal intubated (d3)

TREATMENT: Tienam + Amika +

Fluconazol + TMP + CS

MV 13 days POSITIVE

OUTCOME


10/24

2ND ADMISSION JULY 2006

X-ray 3 (24th of July) WBC=9500/mm3

Ly=33.4%

Mo=9.3%

Gr=57.3%

Ht=28.2%

PLT=814.000/mm3

CRP=6.04 mg/dl

-tachypnea,-fever (39C)

Ceftriaxone + Genta + TMP + CS + Adrenaline (A) + IVIG


11/24


AFTER 7 DAYSX-ray 4 (1st of Aug) PERSISTENCE OF FEVER-39C

WBC = 47.700/mm3

Gr=89.5%

Mo=2%

Hb=8.6g/dl

PLT=1214.000/mm3

Blood smear: toxic granulations

ESR=55 mm/h

CRP=8.27 mg/dl

Tienam (20 days)+Amikacin (7 days)+CS+Adrenaline (A)

After: TMP+Clarithromycin


12/24


Other results:

Blood culture=negative

Mycoplasma pneumoniae serology=negative

ELISA- for Mycobacterium tuberculosis=0 units Mantoux tuberculin skin test (2 Units)=negative

EXTREMELY SLOW FAVOURABLE EVOLUTION


13/24

3RD ADMISSION SEPTEMBER 2006

-Cough

-tachypnea-perioral cyanosis

FOR 3 DAYS

X-ray 5


14/24

Weight curve

0

1000

2000

3000

4000

5000

6000

nastere 3 sapt 2 luni 3 luni 4 luni

AGE

Weigh

t(g)

Birth 1 m.o. 2 m.o. 3 m.o. 4 m.o.

Ideal weight

Measured weight


15/24

3RD ADMISSION JULY 2006

WBC=45.300/mm3

Ly=10.6%Mo=5.7%

Gr=83.7%

Hb=9.7g/dlHt=28.9%

PLT=1152.000/mm3

ESR=65 mm/h

Cefuroxime+Fluconazol

+Adrenaline (A)4 d: WBC=56.900/mm3

Ly=15.8%Mo=0.5%

Gr=83.7%


16/24


CARDIAC ECHO: NORMAL

Both lungs, inflated, transsonic area on the

left base (loculated pleural effusion?)


17/24

3RD ADMISSION JULY 2006THORACIC CT

Multiple

mediastinal

nodules withperipheral

enhancementand a centralhypodensearea (23/18 mm)


18/24

3RD ADMISSION JULY 2006THORACIC CT

Opacity of both upper

lobes + bronchogram

on the left

Multiple pulmonarynodules (bronchogenic

dissemination)


19/24

3RD ADMISSION JULY 2006CHEST X rays - MOTHER



20/24

3RD ADMISSION JULY 2006Pneumology Consult

DIAGNOSIS:

SEVERE PULMONARY TUBERCULOSIS:

MYCOBACTERIUM TUBERCULOSIS present

(STAIN AND CULTURE FROM GASTRIC FLUID)

TREATMENT (for 9 months):

HIN (10 mg/kg/d) + RMP (10 mg/kg/d) + PZM (30mg/kg/d) + SM (30 mg/kg/d) 6/7 2 months

SLOWLY FAVOURABLE EVOLUTION

AFTER: HIN (10 mg/kg/d) + RMP (10 mg/kg/d) - 6/7 7 months


21/24

NEONATAL TUBERCULOSIS

CONGENITAL (Cantwell criteria): TB lesions in the first week of life

Primary hepatic lesions (hematogenous spread)

TB lesions in the placenta and maternal genital tract

Exclusion of postnatal transmision (all patients contacts arehealthy and the mother hadnt respiratory symptoms and herchest Rx is normal)

PERINATAL ACQUIRED (aspiration or ingestion ofinfected amniotic fluid): lung or gastrointestinal infection


22/24

CONGENITAL TUBERCULOSIS:

CLINICAL PICTURE (HUDSON)

Onset: first days-2-4 weeks

NONSPECIFIC SIMPTOMS: hepatosplenomegaly Respiratory distress Fever Lymphadenopathy Abdominal distension

Lethargy/irritability Ear discharge Papular skin lesions


23/24


24/24

BIBLIOGRAPHY

Congenital tuberculosis presenting as sepsis syndrome: case report and review of theliterature. M.A. MAZADE, E. M. EVANS, J. R. STARKE, A. G. CORREA Pediatr Infect Dis J,2001;20:43942 Vol. 20, No. 4

Congenital Tuberculosis: A Case Report. L.C. S.Vilarinho. The Brazilian Journal of InfectiousDiseases 2006;10(5):368-370.

Congenital tuberculosis in a premature infant. J. Sthelin-Massik, T. Carrelb, A.Duppenthalerc,G. Zeilingera, H. E. Gnehma. SWISS MED WKLY 2002;132:598602 www.smw. c h

Congenital Tuberculosis: A Case Report. P. Nicolaidou, F. Psychou, K. Stefanaki, A.Tsitsika,V.Syriopoulou. Clin Pediatr. 2005;44:451-453

Congenital Tuberculosis.S. M. POLANSKY, A. FRANK, R. C. ABLOW, E. L. EFFMANN. Am JRoentge nol 130:994-996, May 1978

Tuberculosis and Pregnancy.G.C. Khilnani. Indian J Chest Dis Allied Sci 2004; 46 : 105-111

Congenital Tuberculosis. M.F. Cantwell, Z. M. Shehab, A. M. Costello, L. Sands, W.F. Green,E.P. Ewing, S. E. Valway, I. M. Onorato. The New England Journal of Medicine. Vol. 330:1051-1054.April 14, 1994. Number 15

Tuberculosis in the newborn: an emerging disease. M. ADHIKARI,P. THILLAGAVATHIE, P.DEVADAS GANESH. The Pediatric Infectious DiseaseJournal:Vol.16(12) December 1997pp1108-1112

Congenital Tuberculosis in Two Infants.A. Chen, Shin-Lin. AJR:182, January 2004

.
http://content.nejm.org/content/vol330/issue15/index.shtmlhttp://content.nejm.org/content/vol330/issue15/index.shtml

Documents

Tuberculoza neonatala