TWO CASES OF NEO-NATAL TUBERCULOSIS.

JEAN BUCHANAN, m.b., ch.b.

from the Royal Hospital for Sick Children, Glasgow.

The following are reports of two cases of infants dying of miliary tuberculoses in the neo-natal period. The first (P.H.) is an example of

congenital tuberculosis : in the second (M.M.) the infection was acquired after birth and although the condition was not suspected during life,

subsequent re-questioning of the mother revealed a history of exposure to tuberculosis.

CASE REPORTS.

Case 1. (P.H. a male born 28th July, 1943). There had been one previous pregnancy in 1934, a boy, now 11 years old, alive and well. During this second

pregnancy the mother had some chest condition and at the birth of the child was

very ill. The child was born spontaneously, and cried at once. Because of vomiting and refusal to suck he was brought to hospital and admitted at 1.30 a.m. on the 29th July, 1943, when approximately 24 hours old. On admission his weight was 2.5 kg. and his length 45 cm. He was jaundiced and there were haemorrhages into the conjunctiva of the right eye and many petechiae over the forehead. Because of the

child's poor condition, examination was at this time very cursory, but the spleen and liver were not noted to be enlarged. Shortly after admission he began to take convulsions. His condition rapidly deteriorated and he died at 2 p.m. on the 30th July, 1943, when 48 hours old.

Post-mortem examination : Both lungs were found to be the seat of miliary tuberculosis with widespread distribution of tubercles on the visceral pleura covering all lobes of both lungs. The various groups of thoracic glands on both sides were enlarged and caseous. The liver was riddled with miliary tubercles while a few

larger bile-stained tuberculous areas were present immediately under the capsule. The largest of these areas measured 0.5 cm. in diameter. There were no sign of disease in the wall of the umbilical vein. The spleen showed a few nodules under the

capsule. No tubercles were seen in the kidneys, adrenals, pancreas or gall-bladder and the gastro-intestinal tract appeared healthy throughout. There was no trace

of meningeal disease.

The mother of this infant died of tuberculosis in December, 1943, six months after the birth of the patient. There would seem to be little

doubt that the foetus was infected in utero and indeed that the tuber-

culous process which was at its most advanced stage in the liver had

progressed to a considerable degree before birth. It is surprising that death did not occur before birth, and the fact that the infant was not stillborn would suggest that the infection could not have taken place before about the 7th month, if as early. One must presuppose a tuber-

culous bacillaemia in the mother with probably the formation of tubercles in the placenta. At any rate the bacilli gained entrance into the blood

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14 GLASGOW MEDICAL JOURNAL \

stream of the foetus and via the umbilical vein initiated the first lesions

in the liver. Wide dissemination even to the lungs and the rapid progress of the disease process causing death are then readily explained.

Reports of congenital tuberculosis are not common. Probably the first case to be recorded was one seen by Jacobi in 1861, and quoted by him in his article on tuberculosis in Keating's Cyclopedia of the Diseases of Children published in 1890. The mother had suffered from tuberculosis previous to her marriage and died three weeks after her first confinement. The foetus was born after seven months gestation and only lived a few minutes. There were

"

numerous miliary tubercles in the liver near the

surface, a few in its peritoneal covering and in the spleen and on the pneumonary pleura." Beitzke (1935) published a comprehensive review of the literature and of the 100 cases surveyed, he regarded only 61 as true examples of congenital tuberculosis. Price (1937) reported a case interesting in so far as there were present in the lungs several foci which could have been mistaken for lesions of exogenous origin. Case 2. (M.M. a female born 18th June, 1944). The patient was the third

child in the family. Her birth weight was 5 lbs. She cried at once. She was fed on two ounces of diluted milk and a teaspoonful of su^ar every

four hours for. the first

fortnight; thereafter on a dried milk preparation. She did not take her feeds well

and failed to thrive satisfactorily. On 9th J uly, when three weeks old, she suddenly became worse and was sent to hospital.

On admission she was deeply cyanosed and unconscious. The breathing was

very shallow. Her weight was 2.0 kg. and length 43 cm. Heat and stimulants were

given but the infant died ten hours after admission.

Post-mortem examination : There was slight but distinct swelling with partial caseation of the glands above and below the tracheal bifurcation on both sides and also slight enlargement of both sets of hilar glands. The sub-pleural surfaces of both

lungs were thickly studded with miliary tubercles. The lungs felt dense and heavy as if consolidated. The glands throughout the mesentery were slightly enlarged and contained small caseous foci. Those in the ileo-caecal angle showed the most ex- tensive caseation. Several small tuberculous nodules were present in the distal

Feyer's patches but none had broken down or ulcerated. A small tuberculous lesion was present in the caecum. No naked eye evidence of tuberculosis was present in the liver which showed merely fatty mottling, or in the spleen, kidneys, adrenal glands, pancreas or gall-bladder. The brain substance was soft. No trace of tuberculous

meningitis was present. The left choroid plexus was thrombosed and the right one showed a commencing thrombosis. There had been slight haemorrhage into both ventricles and the adjacent cerebral substance.

History obtained subsequently : Until the present incident the parents regarded themselves as healthy and free from tuberculosis. Living in the same "

close " however was a tuberculous family where a son and daughter were affected.

These two young adults were friends of the mother and two days after the birth of the patient had each held the baby for about ten minutes. When two weeks old the infant was also held lying in the bed with the young girl for an hour. The son died

six months later of tuberculosis and the daughter was removed to a sanatorium.

The subsequent history of the mother is also interesting and significant. About six weeks after the death of her infant, she developed a pain in her chest and was

NEQ-NATAL TUBERCULOSIS?BUCHANAN 15

removed to hospital. The radiological diagnosis at this time was pleurisy with effusion but no fluid was obtained on exploratory puncture. She had no cough or fever and tubercle bacilli were never found. Nevertheless the condition was regarded as tuberculous. She remained in hospital for ten months and is now very well. She was interviewed as recently as August, 1945.

In this case there is nothing to suggest congenital tuberculosis. At

autopsy, the lesions showed what appeared to be a respiratory portal of

entry and subsequent spread to the glands in the mesentery. Indeed the

absence of more widespread lesions and of meningeal involvement might lead one to suggest that death was accelerated by the cerebral condition.

That this infant contracted the tuberculous infection from the open cases of tuberculosis to which she was exposed seems reasonable. The

great susceptibility of infants and young children to tuberculosis and indeed to all infections is well recognised. In this instance exposure for

less than half an hour when the infant was two days old proved sufficient to cause the mischief, the infection presumably having taken place at this time. The second exposure of an hour was only one week before death, probably when the lesions in the infant were well established.

Similar cases have been reported. Vallette and Rosenkranz (1935) cited the case of an infant presumably healthy at birth who during the fifth month of life was held in the grandfather's arms on four occasions for half an hour, i.e. two hours contact in all. The grandfather died of tuberculosis two months later. The infant sickened and at 22 years died

of spinal caries and generalised tuberculosis.

The author desires to thank Dr. Stanley Graham for permission to publish these

case-reports and for his advice and criticism. The autopsies were carried out by Dr. K. G. Guthrie, Assistant Pathologist, Royal Hospital for Sick Children. The

work was done during the tenure of a McCunn Scholarship.

REFERENCES.

Beitzke, H. (1935). Ergebn. d. ges. Tuberk-Forsch. 7: I.

Jacobi, A. (1890). Heating's Cyclopedia of the Diseases of Children. II, part I, p. 167. Price, D, (1942). Tuberculosis in Childhood. Bristol. John Wright & Sons. Vallette, A. & Rosenkranz, B. (1935). Rev. franc, de Pe'diat. 11 : 179.