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A rare presentation of a rare disease—congenital tuberculosis presenting as subdural haematoma
  1. V Gali,
  2. R Sathanantharajah,
  3. S Sivakumar
  1. Department of Neonates, Birmingham City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, West Midlands, UK

Abstract

Congenital tuberculosis is a rare disease. Only 21 cases have been reported in English language journals since 2001. Subdural haematoma associated with congenital tuberculosis has never been reported. A 26-year-old cachectic looking, Asian lady presented acutely in labour at 33 weeks. She had an uneventful antenatal period and normal antenatal scans. Fetal distress and a suboptimal cardiotocogram led to emergency caesarean section. Abnormal caseating peritoneal material was noted during the Caesarean section raising suspicion of maternal tuberculosis. The preterm baby girl was born in poor condition and needed resuscitation including mechanical ventilation. Following admission to neonatal intensive care, she was noted to have deranged clotting, thrombocytopenia and anaemia. She received fresh frozen plasma, platelet and packed cell transfusions. Antituberculous treatment was added to the antibiotics, with a suspicion of congenital tuberculosis. Cerebrospinal fluid analysis was highly suggestive of tuberculous meningitis. Following an abnormal cranial ultrasound scan, CT brain confirmed a large left subdural parieto-temporal collection with a significant mass effect. The baby was immediately transferred to the nearest tertiary centre and the subdural collection was urgently evacuated by neurosurgeons. This lead to a dramatic improvement in clinical condition followed by extubation on day 6. Congenital tuberculosis was confirmed by microbiological evidence from baby's gastric aspirate and mother's peritoneal fluid. In this case, the presence of acid-fast bacilli on microscopic examination of the nasogastric aspirate suggests possible ingestion of infected amniotic fluid by the fetus. Secondly, the biochemical and microbiological analysis of cerebrospinal fluid is highly suggestive of tuberculosis meningitis which suggests haematogenous spread of infection from mother. Significant inflammation and disseminated intravascular coagulopathy in tuberculosis could cause subdural haematoma. Early imaging in conjunction to clinical suspicion is the key in managing this complication.

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