Cavitary Tuberculosis in an adult, a common entity, presents as post primary tuberculosis. Its presentation as primary cavitary tuberculosis (PCT) in young infants is rare and in a neonate it’s not even reported. PCT is a devastating disease with serious consequences if not promptly and adequately treated. We report a case in a preterm infant, first of the twins, who became symptomatic early in life with whoopy cough and finally turned out to be PCT associated with military tuberculosis. She had a favourable response to the first line antituberculous drugs.
PCT in young infants is a rare entity and even more so in a preterm neonate. It happens because of caseating necrosis in the primary lesion and its extrusion through the bronchus. It is more common on the right side . In a series of 75 patients of PCT reported by Maniar  youngest patient he had reported was 1.5 months with an average age of presentation being 7-12 months. We report a preterm neonate on isoniazid prophylaxis, first of the twins born to a mother with proven TB on ATT (Antituberculosis Treatment), presenting with a whoopy cough. She was diagnosed both radiologically and bacteriologically as PCT with military tuberculosis. She was treated successfully without any complications.
28 days old female infant first of the twins born at 35 weeks period of gestation with a birth weight of 1.8 kg through Lower Segment Cesarean Section was brought with complaints of incessant whoopy cough, breathlessness and failure to thrive which had started at 20 days of life. Antenatally mother was detected to be sputum positive pulmonary tuberculosis and was started on ATT at 32 weeks of pregnancy. Mother was sputum negative at the time of delivery. Both the neonates were started on INH prophylaxis at birth, chest X-ray at birth was normal. Clinically her weight was 2.0 Kg (<10th centile), Occipito frontal circumference was 36cm (95th centile) and her length was 48cm (75th centile). Temperature was 100 degree Fahrenheit, respiratory rate was 64/minute, pulse was 140/minute, oxygen saturation was 91% in room air reaching to 99% with oxygen. BCG uptake was present. There were diffuse crepitations and rhonchi all over the chest. There was no organomegaly.
Patient was evaluated her hemogram showed hemoglobin of 11gm%, counts were normal. ESR was 30mm at 1 hour. Chest radiograph showed thick walled cavity in upper zone of left lung with military mottling bilateral (Figure 1). Mantoux was 18mm
at 72 hours. Biochemical parameters were normal. Ultrasound of
the abdomen was normal. Cerebrospinal fluid analysis revealed
no abnormality. NCCT Chest scan revealed consolidation with
cavitatory lesion of upper lobe of left lung with military seedling
(Figure 2). Mycobacterium tuberculosis was detected in gastric
aspirate. Infant who was initially strated on empirical antibiotics
was switched to four drugs ATT with isoniazid, rifampicin,
pyrazinamide and ethambutol daily for two months followed by
isoniazid and rifampicin for next four months. After six months of
treatment the baby recovered clinically and radiologically other
sibling did not have any complications.
The rarity of cavitary tuberculosis in infants, the non-specific
nature of the symptoms and associated clinical signs of tuberculosis
in early infancy have been repeatedly commented upon in the
literature with congenital tuberculosis [3-8]. In the present case,
despite the positive history in mother and child on isoniazid
prophylaxis, tuberculosis was not suspected at first and baby was
given antibiotics. A similar sequence has been reported by Chou et
al. .Was the infection congenital or acquired perinatally could
not be answered, as both can present with bronchopneumonia,
miliary mottling, upper and mid zone pneumonia, interlobulitis,
or reticulonodular infiltrations. Congenital tuberculosis infections
tend to be diffuse rather than localized as also described by
Choudhary  in a 52 day old neonate. In this case absence of
extra pulmonary disease despite having miliary seedling in the
lungs made us speculate that the infection was acquired at or
near the time of birth, though the presence of cavitary pulmonary
tuberculosis at only 28 days is remarkable. Endometrial biopsy in
the mother would have identified timing and source of infection
and guided us in initiating early treatment .