A 22-year-old, Guatemalan woman with poor prenatal care was admitted 10 days before delivery to an outside hospital with a 1-month history of fever and a 14-kg weight loss. She had no respiratory symptoms, but her chest X-ray showed diffuse micronodular infiltrates. Sputum and bone marrow biopsies were positive for acid-fast bacilli and were confirmed as M. tuberculosis.
The infant was delivered at 25 weeks in gestation, weighing 757 g, with Apgar scores of 6 and 8. The newborn developed respiratory distress, and a chest X-ray was consistent with respiratory distress syndrome, which prompted transfer to our neonatal unit. Except for a bilirubinemia of 6.9 mg/dL (direct: 0.4), all laboratory tests were unremarkable, and all samples, including gastric lavage, blood, and endotracheal tube, obtained to identify mycobacteria were negative. The child was treated with intravenous and subsequently with oral Isoniazid and never developed signs or symptoms of active TB infection. The infant was ultimately discharged to the care of the mother to complete the course of therapy under supervision of the local health department.
The mother was treated with Rifampin, Isoniazid, Pyrazinamide, and Ethambutol, and the father and 1 sister, both of whom were PPD positive, were treated with Isoniazid.
A review of the many samples of placenta from patient 1, which had been obtained to address the issue of postpartum hemorrhage, was undertaken. A cluster of acute villitis and intervillitis, with a predominant neutrophilic and histiocytic response and no evidence of granulomatous inflammation, was identified in only 1 of the tissue blocks (Fig. 1). An Auramine-O fluorescent stain showed many acid-fast bacteria in this lesion. The liver biopsy revealed non-caseating granulomatous hepatitis with positive acid-fast bacteria on microscopic examination and infection with Mycobacterium tuberculosis (MTb) on culture, despite several weeks of anti-TB therapy.
The placenta from patient 2 showed multiple foci of acute villitis and intervillitis in 15 blocks, and a Ziehl-Neelsen stain showed abundant acid-fast mycobacteria (Figs. 2,3A).
Immunohistochemical studies on both placentas, conducted to identify histiocytes (CD68), neutrophils (Myeloperoxidase), T and B lymphocytes (CD3 and CD20), interdigitating reticulum cells (CD21), and natural killer cells (CD56), were performed using standard methods with an automated Dako Autostainer Plus machine (Dako, Carpinteria, CA, USA).
Both placenta specimens showed intense and diffuse staining of inflammatory cells with CD68 and Myeloper-oxidase (Fig. 3B,C). Adjacent villi to these inflamed areas showed apparent proliferation of Hofbauer cells in the CD68-stained slides (Fig. 3B). The placenta from patient 1 showed some CD3-positive cells in the mixed cellular reaction and apparent activation of CD3 cells in adjacent villi (Fig. 3D). None of the specimens showed CD20-, CD21-, or CD56-positive cells.