Neonatal Tuberculosis:

Neonatal tuberculosis is a serious infection with 50% mortality caused by mycobacterium

tuberculosis and can be either congenital, which is contracted during pregnancy or at the time of
delivery or postnatally acquired tuberculosis, although the clinical features and treatment remains
the same between the two groups.26 Cantwell diagnostic criteria for congenital tuberculosis was
published in 1995 which includes proven tuberculosis lesions plus one of the following27
- Tuberculous lesion in a newborn baby in the first week of life
- Primary liver complex or caseating hepatic granulomas
- Maternal genital tract or placental tuberculosis
- Exclusion of postnatal transmission by a thorough investigation of contacts.
Perinatal transmission of tuberculosis is through endometrial tuberculosis or disseminated
disease in mother, hematogenous spread, amniotic fluid aspiration or ingestion of infected
secretions.28 The definitive lesion of congenital tuberculosis, unlike in older children, is primary
complex of liver with caseating granuloma from which the organism spreads to
gastrointestinal(GI) tract, spleen, kidney, adrenals, bone marrow, meninges and skin.
Uncommonly, primary foci can involve lungs or GI tract from the rupture of placental lesion into
the amniotic fluid.29 Clinically, the affected neonates can present either classically with
hepatosplenomegaly and respiratory distress or manifest like sepsis with non specific signs.
Neonatal tuberculosis can involve any organ systems of the body with features of septicemia,
persistent or recurrent pneumonia, meningitis, lymphadenopathy, jaundice, ascites, disseminated
intravascular coagulation, otitis media, osteomyelitis or paravertebral abscess.30
Diagnosis involves high index of suspicion in a sick newborn who fails to
improve with antibiotics and has negative bacteriological culture. Culture of tuberculous bacilli
from placenta or endometrial curettage along with HIV testing of mother should be done for
suspected congenital tuberculosis. In neonates, confirmation of tuberculosis infection is done by
testing of acid fast bacilli smear and cultures from secretions of tracheal, gastric aspirates,
tracheal biopsy, cerebrospinal fluid. Ultrasonography of the liver and the probe guided biopsy of
liver should be considered in diagnostic dilemmas.31 Coventional Ziehl - Nielson light
microscopy techniques, x ray chest to look for infiltrates, Mantoux test are routinely done in
developing countries. Utility of mantoux test in neonates is poor due to low reactogenecity and
poor helper T cell responses, in addition, negative mantoux does not rule out the disease.32 Gene
xpert (real time PCR) in children is useful in diagnosis of tuberculosis in community settings.
Newer methods such as LED fluorescence microscopy and mycobacterium growth indicator
(MGIT) are effective but are expensive and not easily available in most of the tropical
countries.33
Antituberculous treatment(ATT) should be initiated promptly once culture is
obtained in a neonate with suspected congenital tuberculosis. Even though no guidelines existing
at present for neonatal tuberculosis, intensive phase should be started immediately with four drug
regimen for initial 2 months - isoniazid(INH), rifampicin(RIF), pyrazinamide (PZA), and either
ethambutol (EMB) or an aminoglycoside such as amikacin followed by continuation phase of
isoniazid(INH) and rifampicin(RIF) for 7-10 months and the total duration is usually 9-12
months.34 Mothers who have completed ATT or have received 2 weeks of ATT before delivery
are less likely to transmit the disease to their newborn even if they suffer from extrapulmonary,
miliary, and meningeal tuberculosis. Isoniazid (INH) prophylaxis to the exposed neonate without
disease draws various opinions among experts in different countries.35 American academy of
paediatrics (AAP) recommends INH prophylaxis for neonates who do not have active disease but
whose mother has active TB. For newborns with latent infection (positive tuberculin skin test) at
birth INH should be given till 9 months whereas for those with negative tuberculin test,
prophylaxis continued for 3-4 months followed by mantoux test. If mantoux is negative, stop
INH by 3 months, if positive and baby developed features of congenital TB, treat for the same,
while, if mantoux came positive and no active disease in infant, INH is given for 9 months.36
Infants receiving INH prophylaxis should receive pyridoxine supplementation. Baby and mother
should be separated when mother is sick, not adherent to treatment, has resistant TB or in cases
where a baby born to a mother with suspected or active disease till both have been evaluated.37,38
Mothers on latent TB infection treatment should be encouraged to breastfed their babies and after
at least two weeks of treatment for active Tuberculosis. RNTCP and IAP recommends BCG
vaccination at birth even for those receiving Isoniazid prophylaxis after excluding active
tuberculous infection,37 wheras WHO states that BCG vaccination should be given for neonates
born to mother with pulmonary TB if an infant is asymptomatic, has no immunological evidence
of TB and is HIV negative.38