A 26-day-old male neonate was brought with complaints of recurrent fever and a history of seizures since two weeks old. He was born at term, 2,400 gr, via cesarean section to a confirmed COVID-19 and TB mother. A nasopharyngeal swab for RT-PCR SARS CoV-2 of the baby was negative. He was discharged in good condition from the hospital on the 3rd day and was separated from his mother for 3 weeks. He was never given TB prophylaxis after birth.
At the presentation, he was alert and feverish. No abnormal respiratory findings nor seizures, but tachycardia was identified. An abdominal examination revealed liver and spleen enlargement. The laboratory findings showed decreased platelet counts, an elevated liver function test, and an increase in total bilirubin and c-reactive protein. The HIV serology result was non-reactive, while the viral load was not investigated. A chest x-ray revealed bilateral pneumonia (Figure 1) and an abdominal radiograph concluded a liver enlargement. He was initially diagnosed with late-onset neonatal sepsis and was given a course of empiric antibiotics. The patient had previously received phenobarbital 20 mg/kg body weight at the previous hospital and was immediately referred to our hospital. The drug was discontinued when the seizures stopped without an EEG examination. On the 3rd day of hospitalization, he had tonic posturing, suggestive of meningitis. We did a lumbar puncture and the CSF was clear with increased cell count (9 cells/HPF, mononuclear cells dominant). An X-pert MTB/RIF from gastric lavage detected rifampicin-sensitive Mycobacterium tuberculosis. He has been diagnosed with TBM and decided to start a TB drug regimen. However, we could not give rifampicin and isoniazid due to the increase in ALT and direct bilirubin level, so he was given levofloxacin and ethambutol. The patient did not show any sign of a seizure. However, the video-EEG result showed an electrical seizure (Figure 2). A brain MRI did not show any abnormalities or signs of meningitis.
After starting the TB regimen, his condition slowly improved. The fever was down and there were no clinical seizures. Abdominal sonography showed multiple hypoechoic nodules that were suggestive of liver and splenic TB. He was then diagnosed with suspected congenital disseminated TB. During hospitalization, his liver function improved. Rifampicin and isoniazid were introduced and were well tolerated. After 30 days of hospitalization, evaluation using the EEG showed no epileptiform discharge, and phenobarbital was discontinued. On day 33, he was discharged in good condition.