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DISSEMINATED TB IN A PREGNANT PATIENT

      TOPIC: Pulmonary Manifestations of Systemic Disease
      TYPE: Medical Student/Resident Case Reports
      INTRODUCTION: In the United States, most cases occur in foreign-born individuals immigrating from countries with high rates of endemic TB [1]. Aggressive dissemination of tuberculosis related to pregnancy is rarely reported in the literature; the incidence of TB in pregnancy ranges between 1 and 2% [2, 3]. We report a pregnant patient with the dissemination of tuberculosis who developed CNS symptoms and was found to have numerous brain tuberculomas.
      CASE PRESENTATION: A 33-year-old F P1001 25+5wga, HIV-negative Haitian woman, presented with a non-productive cough and right lower quadrant pain. Patient-reported recent travel to Haiti and history of positive quantiferon test noted during the prenatal period with subsequent negative chest x-ray screening.Initially, during the admission, she started to have low-grade fevers and was saturating 96% on room air. Labs were significant for elevated LFTs and ALK-PHOS. Initial chest x-ray showed bilateral infiltrates. A follow-up chest-CT demonstrated diffuse reticulonodular pattern bilaterally with no lymphadenopathy. There was a concern for multi-systemic sarcoidosis. ACE and 1,25-(OH)2 Vitamin D levels were elevated.The hospital course was complicated by new-onset lethargy and the development of late fetal decelerations, resulting in an emergent caesarian section. Pulse dose steroids were given for presumed multisystemic sarcoidosis.Three days post-delivery, the patient endorsed persistent headaches. An acute change in mentation was noted on the neurological exam, raising concern for a CNS infection. CT head revealed non-obstructive hydrocephalus and hypodensities in the bilateral parietal regions. Follow-up MRI showed ring-enhancing lesions, along with cerebral vasculitis seen on MRA. The pathology report from the placental tissue showed necrotizing granulomatous inflammation and an abundance of acid-fast bacillus. Emergently, the patient was started on treatment for tuberculomas of the brain.
      DISCUSSION: Meningitis and tuberculoma are the two most common forms of intracranial tuberculosis [4]. CNS TB is uncommon in HIV-negative patients [5]. The pathogenesis of TB of the brain initially starts with a rupture of rich focus into the subarachnoid space, heralding the onset of meningitis. The subsequent development of adhesions results in neurological sequelae [6]. Cerebral imaging is essential to establish the diagnosis of and disclose hydrocephalus, basilar meningeal thickening, and tuberculomas [3].
      CONCLUSIONS: Although a multidisciplinary approach was taken, we feel that the administration of pulse dose steroids allowed the reactivation of disseminated TB, ultimately resulting in our patient's demise.
      REFERENCE #1: Amin S, Stone D, Anderlind C. A 32-Year-Old Woman With Miscarriage, Headache, Hepatitis, and Pulmonary Disease. Chest. 2019 Apr;155(4):e101-e105. doi: 10.1016/j.chest.2018.10.001. PMID: 30955580.
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