Title : Reactivated disseminated tuberculosis in pregnancy despite repeated negative AFB testing
Abstract:
Disseminated tuberculosis (TB) is a life-threatening condition resulting from massive hematogenous spread of Mycobacterium tuberculosis leading to infection of various organ systems. It can occur in the setting of primary infection or reactivation of latent infection. Patients often present with nonspecific symptoms and confirmatory lab testing can be time-consuming, making diagnosis difficult. Therefore, maintaining a high clinical suspicion is imperative for early diagnosis and treatment. We discuss a 29-year-old pregnant female who initially presented to the hospital with several weeks of vaginal bleeding in the setting of PPROM (pre-term premature rupture of membranes).
She was found to be febrile, tachycardic, and hypotensive requiring vasopressor support prior to undergoing D&E in the setting of maternal sepsis with nonviable pregnancy. Her course was complicated by persistent headache and fever with unclear cause. Initial MRI at another hospital revealed multifocal areas of signal abnormality in bilateral hemispheres, cerebrum, and brainstem.
Repeat MRI with flair showed ring-enhancing lesions within these areas as well as parenchymal edema and nodular leptomeningeal enhancement of the right parietal lobe. Lumbar puncture showed elevated WBC with neutrophil predominance (248), low glucose (20), and elevated protein (90). Despite treatment with broad spectrum antibiotics, the patient continued to fever, and intracranial biopsy was pursed which revealed gliosis without evidence of inflammation or malignancy. She began experiencing respiratory symptoms with CT chest demonstrating diffuse bilateral disease with reticular pattern. Bronchoscopy was performed with BAL and cultures were negative. Notably bacterial DNA, fungal DNA, MTB DNA, non-tuberculosis mycobacterial DNA, and BAL AFB smears were negative. She developed neurological symptoms for which MRI of the spine was obtained and showed enhancing foci at multiple locations within the spinal cord. Infectious disease was consulted to assist with management. During broad infectious workup, patient was found to have positive QuantiFERON gold and history revealed her to be from a known endemic region. Given above findings, there was high suspicion for disseminated tuberculosis in setting of immunocompromised state secondary to recent pregnancy and septic abortion.
RIPE therapy along with steroids was initiated, intermittently held due to elevated liver enzyme, and resumed in a stepwise fashion. She was discharge with plan for directly observed therapy (DOT) and close outpatient ID follow up. This case illustrates the importance of maintaining high clinical suspicion for tuberculosis infection despite negative culture data. In unclear cases, a broad workup and detailed history is imperative to ascertain risk factors. By considering the overall clinical picture, imaging, and laboratory testing, appropriate treatment can be initiated quickly to prevent further life-threatening complications.
Audience Take Away Notes:
- Report a clinical case in which negative testing does not equal absence of disease
- Review diagnostic process involved in latent and/or disseminated tuberculosis
- Discuss an often-overlooked cause of immunocompromise
