A 26-year-old multiparous woman from Ghana, with a history of positive PPD (purified protein derivative) test and gestational diabetes, presented to labor and delivery at 38-week gestation with complaints of suprapubic pain, pressure, and possible leakage of amniotic fluid.
The patient's suprapubic pain had occurred for a week and was associated with vomiting. The patient also complained of a productive cough for the past 3 to 4 months with a decrease in vision occurring at the start of pregnancy. She reported good fetal movement and denied vaginal bleeding. She also denied the use of alcohol, tobacco, and illicit drugs. The patient had a history of positive PPD with a normal chest X-ray in 2009. Treatment never occurred as the patient was lost to follow-up.
Physical examination revealed a frequent productive cough with urinary incontinence. The patient had a visual acuity worse than 20/200 in each eye and was referred to ophthalmology. Ophthalmology diagnosed her with optic atrophy OS (left eye) and papillitis, choroiditis, and uveitis OD (right eye). She was prescribed ophthalmic prednisolone and cyclopentolate for the uveitis and timolol for secondary glaucoma due to the uveitis. However, the patient refused all eye medications stating that headaches and eye pain occurred with use.
The patient was also evaluated by pulmonology for chronic cough. Initial imaging was delayed due to patient refusal. The mother believed that imaging would be harmful to the fetus and would not consent to the procedure.
Day one after admission the patient delivered a healthy infant of 2960 grams at 38 weeks via vacuum assisted vaginal delivery. APGAR score was 9/9 with no perinatal complications. After the patient delivered, a chest X-ray (CXR) showed right nodular opacity in the apex of the lung field measuring 1.6 x 1.0 cm (Figure 1(a)). Mycobacterium tuberculosis was confirmed by positive AFB smear and culture leading to the diagnosis of active TB.
The baby was isolated from the mother and fed with formula due to increased likelihood of TB transmission. Physical examination performed on the newborn revealed no anatomic, visual, or neurologic deficits. As a safety precaution, the infant was initiated on isoniazid oral suspension of 0.1 mg and pyridoxine oral suspension of 29 mg daily (10 mg/kg/day).
Immediately following maternal diagnosis of active TB, the patient was isolated and started on an antituberculosis regimen comprising of isoniazid and pyridoxine 300 mg once daily, rifampin 300 mg twice daily, pyrazinamide 500 mg three times daily, and ethambutol 1,200 mg daily to be completed on a 6-month course. However, ethambutol was discontinued due to the patient's history of left optic nerve atrophy, which may progress due to ethambutol toxicity.
Prior to being discharged, a CXR was done on April 7, 2015, which revealed increased density in the right upper lobe that appeared to be more prominent compared to the previous imaging (Figure 1(b)). On April 13, 2015, the patient was cleared for discharge after the documentation of three consecutive partially negative AFB smears and culture. She was released to the care of a public health advisor at the Department of Health who will provide follow-up care.