A Challenging Case of Miliary Tuberculosis in Pregnancy

Abstract

Miliary tuberculosis (TB) is an uncommon yet severe condition that can pose substantial risks to pregnant women and their unborn child. This case study describes a 22-year-old pregnant female at 23 weeks of gestation presented with breathlessness, fever accompanied by chills, dry cough, and loss of appetite. With no significant comorbidities, her initial symptoms were inconclusive, leading to her initial diagnosis as a case of pyrexia of unknown origin. Despite receiving iron supplements for anemia and broad-spectrum antibiotics, her health continued to decline, prompting her transfer to a specialized medical center where advanced molecular testing ultimately confirmed a diagnosis of miliary TB. Upon admission, she was promptly started on anti-TB therapy and managed in the intensive care unit, where her clinical course included the development of acute respiratory distress syndrome (ARDS) requiring ventilatory support. Through meticulous monitoring and multidisciplinary intervention, the patient stabilized and ultimately delivered a healthy baby girl through normal vaginal delivery. Miliary TB, though rare, is challenging to diagnose during pregnancy due to overlapping symptoms with other conditions. This case underscores the critical importance of recognizing the atypical presentations of miliary TB in pregnant women, particularly in the context of previous exposure. It highlights the need for high clinical suspicion, timely diagnosis, and comprehensive management strategies to ensure favorable outcomes for both mother and child in the face of such challenging clinical scenarios.

INTRODUCTION

Miliary TB poses significant diagnostic and therapeutic challenges due to its diverse clinical manifestations and the potential for rapid disease progression, it accounts for ~0.15%–10% of all TB cases and miliary TB in pregnancy ~1% of cases.^[1] Pregnancy-related TB endangers the health of both women and their fetuses and is considered an important cause of morbidity and mortality due to significant diagnostic and therapeutic challenges, potential for rapid disease progression and nonspecific presentation. Acute miliary TB, a more serious and potentially lethal form of the disease, results from massive hematogenous dissemination of (MTB).^[1]

The relationship between the maternal immune system and tuberculosis (TB) infection during pregnancy is complex and multifaceted. Pregnancy naturally suppresses the immune system to prevent it from attacking the fetus, which is considered foreign due to the paternal antigens. This suppression can make pregnant individuals more susceptible to infections, including TB.^[2] The objective of this clinical case report is to enlighten and focus on the unusual presentation of miliary TB in a young pregnant female.

CASE REPORT

A 22-year-old woman in her second trimester of pregnancy presented to a local Community Health Center. At 23-week gestation, she had profound fatigue, generalized weakness, and a decrease in appetite, which she initially attributed to pregnancy. She had no significant medical conditions. Her initial laboratory tests showed mild anemia (Hb of 9.2 g/dL). The timeline of the case presentation is depicted in Figure 1.

Figure 1: (a) Timeline of major events in clinical case, (b) Contd: Timeline of major events in clinical case

After 4 weeks, she visited the district hospital, with the complaint of having persistent low-grade fever for 7 days, increasing fatigue, and shortness of breath. However, her symptoms persisted and progressively worsened over the next 4 days.

At this point, the patient has a high-grade fever, severe breathlessness, and dry cough. On physical examination, she was febrile, visibly fatigued, and SpO₂ was >94%, raising concerns about her respiratory status. A chest X-ray [Figure 2] revealed diffuse, bilateral nodules >5 mm in diameter, suggesting interstitial lung disease. Her condition continued to deteriorate despite giving intravenous antibiotics, including piperacillin–tazobactam and ceftriaxone, along with oral azithromycin. Sputum was tested negative for acid-fast bacilli, ruling out pulmonary TB, other tests for dengue and malaria were also negative. Due to the progressive nature of her respiratory distress, she was referred to the tertiary care center for further evaluation.

Figure 2: Chest X-ray depicting diffuse bilateral nodules <5mm in diameter each

She was in severe respiratory distress, had developed tachycardia and, a high fever, and was unable to maintain adequate oxygen saturation despite supplemental oxygen. Her pregnancy added another layer of complexity, as careful monitoring of both the mother and the fetus was required. She gave contact history with a TB-positive patient 2 months back. A high-resolution computed tomography scan [Figure 3] of the chest revealed diffuse miliary nodules across both lungs – raising the suspicion of miliary TB. Further diagnostic tests, including GeneXpert MTB/rifampicin (RIF) assay and a line probe assay [Figure 4], confirmed the presence of MTB that was sensitive to first-line anti-TB therapy (ATT), including RIF and isoniazid.

Figure 3: High-resolution computed tomography depicting diffuse miliary nodules across both lungs

Figure 4: Line probe assay, confirmed the presence of that was sensitive to first-line anti-tuberculosis drugs, including rifampicin and isoniazid

She was immediately started on ATT and other antibiotics.

Blood cultures were sent in on Day 2 of admission to the hospital, which reported a multidrug-resistant (MDR) complex isolate that was susceptible to tobramycin and intermediate to amikacin. ATT was continued for the patient. However, the patient’s clinical condition continued to worsen, and she developed acute respiratory distress syndrome (ARDS) on Day 11 of hospitalization. She required a tracheostomy and was put on ventilatory support. On Day 16, grade fever persisted and total leukocyte count was elevated. The use of corticosteroids was considered to manage the inflammation associated with ARDS, but careful attention was given to the possible teratogenic effects of these drugs on the fetus. Throughout this period, fetal monitoring [Figure 5] was meticulously carried out to ensure the well-being of the unborn child. On Day 26, the patient was finally weaned off the ventilator and a repeat set of blood and TT samples were sent on for culture and sensitivity testing. MDR complex was isolated. On Day 34, significant derangements in liver function test (LFT) were observed. On Day 37, the patient was diagnosed with drug-induced hepatitis on account of which ATT was stopped and the patient continued steroid treatment. Soon after as the patient became hemodynamically stable, she was transferred to the ward and finally discharged on Day 42 with advice to review with LFT reports and restart ATT once the hepatitis is settled. Despite the critical condition, the patient delivered a healthy child at 38-week gestation. The newborn showed no signs of congenital TB or any other complications, and both mother and child were closely followed up in the postnatal period.

Figure 5: Ultrasound depicting normal heart rate and rhythm for the fetus

DISCUSSION

This case highlights a 22-year-old pregnant woman who presented with symptoms of miliary TB at 23 weeks of gestation. Her clinical course was complicated by respiratory distress, fever, and anemia, culminating in her transfer to a tertiary care facility where she was diagnosed and treated for miliary TB.

Miliary TB during pregnancy, though rare, poses significant risks to both maternal and fetal health. Studies have shown that pregnant women with TB are at higher risk for severe complications, such as ARDS and maternal mortality, particularly in cases of disseminated disease.^[3,4] In our patient, initial symptoms included breathlessness and fever, aligning with findings by Wang et al.,^[5] who reported that common clinical presentations of miliary TB can be misinterpreted as other infections during pregnancy.

In this case, the patient had a positive contact history with a TB-positive individual, which is crucial in understanding the transmission dynamics of the disease. It emphasizes the importance of screening and preventive measures in pregnant women, particularly those with known exposure. The presence of anemia and low Vitamin D levels (19.1 ng/mL) may have contributed to her susceptibility, as noted by Khan M et al. (2001),^[4] who identified these factors as potential risk enhancers for TB in pregnant populations.

Following her transfer to a tertiary care hospital, diagnostic investigations revealed miliary TB through acid-fast staining and GeneXpert, consistent with the findings of Gai et al.,^[6] which underline the efficacy of rapid molecular diagnostics in detecting MTB in critically ill pregnant patients. The initiation of ATT was timely; however, the patient developed ARDS, necessitating tracheostomy and ventilatory support, reflecting the severe clinical course that miliary TB can take, as highlighted in the literature.^[7]

Despite maternal deterioration, the fetus demonstrated resilience, emphasizing the need for comprehensive antenatal care. The patient’s subsequent stabilization and successful delivery of the newborn demonstrate that with appropriate management, favorable maternal and fetal outcomes can be achieved, even in complicated cases of TB. This aligns with the conclusions drawn by Torun Parmaksiz et al.,^[8] who noted that MDR TB in pregnancy could still allow for successful outcomes with aggressive treatment.

Continuous fetal monitoring throughout her hospitalization confirmed the fetus’s well-being, reaffirming the notion that prompt and adequate treatment of maternal TB can protect fetal health. The management strategies implemented in this case serve as an essential reminder for healthcare providers to maintain a high index of suspicion for TB in pregnant women presenting with respiratory symptoms, particularly in regions with higher endemicity. The case highlights the paramount importance of promptly initiating ATT to mitigate disease progression.

CONCLUSION

This case report highlights a unique instance of miliary TB in a young pregnant woman, emphasizing the need for vigilance in recognizing atypical symptoms. Miliary TB presents a formidable challenge in diagnosis and treatment, given its varied clinical manifestations and potential for swift progression. Accounting for only about 1% of all TB cases, its nonspecific presentation can lead to initial misdiagnosis. However, a proactive medical intervention and early treatment initiation enhanced the prognosis for both mother and child in such challenging cases. Miliary TB disease in a pregnant female is rare, and only a single patient was identified from our database, the accrual of additional cases will help delineate the varied clinicopathological presentations and treatment outcomes more appropriately.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.