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Katumba-Lunyenya et al present a fascinating but sad case.
ROUTE OF INFECTION AND INFECTIVITY
Neonatal tuberculosis is usually caused by someone, usually the mother, with open pulmonary tuberculosis coughing on the baby.1 This mother apparently did not have open tuberculosis, so spread must have been transplacental, leading to disseminated, congenital tuberculosis. Did the baby have clinical or autopsy evidence of extrapulmonary tuberculosis?
Most children with tuberculosis disease are not contagious. Exceptions include children with adult-type cavitary lung disease, those with sputum that is smear positive for acid fast bacilli, and those with congenital tuberculosis.2 This baby falls into both the last two categories, and artificial ventilation is likely to have increased the dissemination of bacilli by aerosol, as happens when a patient with chickenpox is ventilated.
HOW TO PREVENT EXPOSURE OF OTHER BABIES AND STAFF?
It is simplistic to say that a high index of suspicion of the diagnosis of neonatal tuberculosis, with early empirical treatment and isolation of suspect cases, is ideal. Neonatal tuberculosis is notoriously difficult to diagnose, especially in preterm babies requiring intensive care.3 Symptoms mimic bacterial sepsis, and the diagnosis is often delayed.1,3 What is more, many neonatal units do not have the facility to isolate a ventilated neonate, necessitating transfer of infectious neonates. There is also the risk of catching tuberculosis from the mother in cases associated with open maternal tuberculosis.
DEFINITION AND MANAGEMENT OF CONTACTS
Contact tracing in this situation is essentially no different from other tuberculosis exposures, and should be carried out by the local health authorities.1,2 All newborns in the nursery at the same time are contacts, even if ventilated. Newborn contacts constitute a high risk group, for which prophylactic isoniazid is recommended. Tuberculin skin testing after three months dictates further management: if negative, stop the isoniazid; if positive, examine the baby, obtain a chest radiograph, and if no evidence of infection, continue isoniazid to nine months.2 BCG vaccine reduces the risk of tuberculosis in exposed infants, but protection is not absolute.1,2 Isoniazid resistant BCG is no longer available, so BCG cannot be given simultaneously with isoniazid. United Kingdom4 and Australian5 authorities view BCG vaccine as an important adjunct to isoniazid, to be given to tuberculin negative tuberculosis exposed babies, especially if continued exposure is likely. BCG vaccine should not be given to HIV positive patients.3–5
A final ethical point. I believe that the prognosis of a 25 week gestation baby places an obligation on neonatologists: intensive care should not usually be initiated, and certainly not continued, without parental informed consent. In this case, the father can scarcely be deemed to have given informed consent to neonatal care if he was unaware of his baby’s risk of HIV infection.
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