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Premature and Congenitally Diseased Infants

by Julius H. Hess, M.D.

Chapter XVI
Tuberculosis in Prematures

The recorded cases of tuberculosis affections during the first weeks of life are unusually rare, and their clinical symptoms, even when anatomically demonstrable changes are present, ordinarily are not to any extent characteristic. While in comparison with the acquired tuberculosis, the congenital form is almost a rarity, nevertheless numerous authentic instances are on record.

M. Pehu and J. Chalier [1] have collected 51 cases from the literature, the authenticity of which has been established. While some of these cases have resulted in premature birth, the majority have been born at full term; and though some of the latter have been well developed, most of them have suffered from congenital debility.

Planchu and Devin [2] describe 39 premature infants born of tuberculous mothers. They believe that the morbidity and mortality is greater in infants born prematurely from tuberculous mothers than the average for those born prematurely of other causes.

While infants born at full term of tuberculous mothers may occasionally be well developed, the majority nevertheless, if infected with tuberculosis before leaving the uterine cavity, show marked congenital debility. As a case in point in evidence for the possibility of good development, may be cited the infant of H. Rollet [3], which died forty-eight hours after birth, but in whom large caseous areas were found in the bronchial glands, lungs, liver, and spleen. The mother of this child died eighteen days post partum from miliary tuberculosis, and on examination it was found that the uterus still contained placental remnants from which numerous tubercle bacilli were obtained.

In cases of intra-uterine infection the tubercle bacilli penetrate into the body of the infant, either by way of the placental blood or by the swallowing of liquor amnii. It is impossible for the embryo to become infected unless the mother be tuberculous.

The transmission of the bacilli from the mother to the infant can occur at any time during pregnancy. This may result from bacilli carried in the fetal circulation, from various parts of the mother's body, or through organisms found in placental lesions. The normal placenta is usually conceived to be a filter impermeable to bacteria. Presumption for the passage of tubercle bacilli from the blood of the mother to that of the infant is a lesion of this filter. Tubercle bacilli can pass into the blood stream of the infant only when a communication has been established between the inter-villous spaces and the blood vessels of the chorionic villi, or when liquor amnii becomes infected with the organisms. Therefore, the bacilli infecting the fetus must come either from a tuberculous placenta or from the circulating blood. The transmission of the bacilli into the blood of the infant takes place when a blood vessel of the villus becomes eroded or ruptured.

Tuberculous changes in the decidua vera or in the chorionic covering of the placenta may result in infection of the liquor amnii by breaking through the amnion, and also in intestinal infection with eventual general systemic distribution.

The intra-uterine infections above described may lead to advanced tuberculous processes at birth. Such infants are usually born premature or show great debility. Not infrequently the infant is infected through the transmission of the organisms during birth, when in the separation of the placenta the blood vessels of the villi become ruptured, and thereby passage to the blood of the infant, either from the tuberculous foci of the placenta, or from the maternal blood, is made possible. In these latter cases no specific changes are found in the organs at birth, and these infants are likely to be well developed.

Intrapartum infection may take place through swallowing or more rarely through inhalation during the passage of the child through the birth canal.

The infection may take place after birth (acquired tuberculosis). This occurs either by way of the respiratory tract through inhalation, or by way of the digestive tract, or through other portals of entrance, far less common.

It is of the greatest importance from the clinical point of view to separate the infants who are born with tuberculous organic changes from those who are born without such pathology. The new-born infant in this situation is in the stage of incubation for tuberculosis.

Unfortunately such clinical distinction is usually impossible because of the absence of pathognomonic symptoms, and the failure of specific tests during the first weeks of life. While the cutaneous and intracutaneous reactions are rarely seen before the fourth week of life, a few cases have been described. Among these is that of Zarlf [4], who reported a positive von Pirquet reaction in a seventeen-day old infant, which was still living at the time of the report, six weeks after birth. In the discussion of this case von Pirquet remarked that this was the earliest age at which a positive reaction had been reported to his knowledge, and that he believed it to be proof of the congenital origin of the case, as his conception was that at least four weeks must pass after the time of infection before a positive tuberculin reaction may be obtained.

It should be remembered that prematurity and congenital debility on the part of infants born of tuberculous mothers does not necessarily mean that the child is suffering either from congenital or hereditary tuberculosis. It should not be forgotten that infants infected with tuberculosis, in whom there are only minor or no tuberculous lesions, may be born at full term, seemingly robust.

Etiology. -- The frequency of tuberculosis as an etiological factor in premature births or general debility of full-term infants must be considered: (1) from the standpoint of the effect of tuberculosis on the entire organism of the mother; (2) its influence on the generative organs of the mother; (3) its effect on the general development of the fetus; (4) of a systemic infection of the fetus; (5) from the viewpoint of the results as they affect the future development of the infant, which may be born at full term, without manifest evidence of congenital debility.

1. Effect of Tuberculosis on the Entire Organism of the Mother. -- While numerous authentic cases of congenital tuberculosis are now on record, by far the majority of infants born of tuberculous mothers do not show evidence of systemic tuberculosis at autopsy, and in our own studies of such instances in the Cook County Hospital over a period of several years, the only well-authenticated case which has come under observation and which has proven to be one of general tuberculosis on the part of the infant, was reported by Grulee [5]. The infant died on the eleventh day after its birth, and at autopsy showed a generalized tuberculosis, affecting most markedly the abdominal organs and especially the periportal lymph glands, liver, and spleen. The tuberculosis was miliary in type, but the stage of the tubercles suggested an intra-uterine infection. The mother was still living several months after the infant's death.

In contradistinction to this case we have had occasion to observe numerous instances in which the infants born of tuberculous mothers have survived, and have either progressed more or less normally, or have died of infections other than tuberculosis -- in whom at least tuberculosis could not be demonstrated at autopsy.

2. Effect on the Generative Organs of the Mother. -- Tuberculosis can be transmitted through the uterus, either through local lesions or without demonstrable lesions in the uterus or placenta. G. Leunberger [6] contributes records of two interesting cases of placental and congenital tuberculosis, which illustrate the abovementioned possibilities. In the first instance the mother died of tuberculous meningitis and miliary tuberculosis. Tubercle bacilli were found in the fetal liver and numerous miliary tubercles in the placenta. Injection of a small piece of liver extract and of the heart's blood of the fetus into a guinea-pig gave rise to pulmonary tuberculosis.

In the second instance the mother suffered from pulmonary tuberculosis, and aborted. Neither the fetus nor the placenta showed any tuberculous changes, but tubercle bacilli were found in the intervillous spaces of the placenta.

From the study of these two cases Luenberger draws these conclusions: When the mother suffers from acute miliary tuberculosis, there can develop numerous miliary tubercles in the placenta, and from these, tubercle bacilli can penetrate the fetal circulation. It is also true that without tuberculous changes in the placenta or membranes the bacilli can pass from mother to child, that is, during birth there can be sufficient injury to the chorionic vessels to allow the bacilli to pass from the intervillous spaces into the fetal circulation.

A. Dietrich [7] reported a case which suggests the possibility of congenital infection. A woman with general tuberculosis gave birth shortly before her death to a premature infant. Tubercle bacilli were demonstrated in the placenta. The baby was never in contact with the mother. It developed well for the first two months, when an abscess formed in the right groin. Following this there was loss in weight and rales in the chest. The child died in the third month. Autopsy showed many tubercles in the lungs, intestines and spleen, a few in the liver and a large lesion in the portal vein.

Tuberculosis of the placenta has been described by many observers. This is of importance in relation to tuberculosis of the fetus in proportion as the fetal or maternal portion of the placenta is involved. It is certain that in many cases only the maternal portion is infected, the fetal remaining uninfected.

3. Effect on the General Development of the Fetus. -- In a consideration of this class of cases, theoretically it may be viewed from two standpoints: (1) That of general debility, without reference to a special predisposition to tuberculous infection; and (2 ) that of congenital predisposition to tuberculous infection. The question of the possibility of an inherited immunity against tuberculous infection is one which is open to great speculation, and we have not been able to satisfy ourselves that such an immunity may exist. That many of this class of infants seem to have a predisposition to tuberculous infection, which in all probability is, however, at least in great part due to their constant exposure and repeated infection with the organisms through contact with an infected mother, cannot be denied. This class of infants without really having tuberculosis often shows signs of malnutrition. Doubtless many of them have a diminished resistance to all infections and more especially to tuberculosis. They are below the average in development.

4. Systemic Infection of the Fetus. -- If tuberculous changes are present in the body at the time of birth, if the infant is born alive, the disease leads to early death in the majority of cases, generally within the first week of life.

In a great number of cases in which tuberculosis is transmitted in utero, more especially in the last days of pregnancy, or intra-partum, the disease remains clinically latent during the first days of life, and may not become manifest for two or three months. The infection may, however, be entirely overcome. These cases may be described as the latent forms of tuberculosis. Of the 28 instances of congenital tuberculosis of which we have definite records at hand, 10 infants were born prematurely, and 2 of these were still births. Two of the living premature infants survived for three months, the other 6 living from one day to two months. Of the infants born at full term all died before the fifth month of life.

5. Results as They Affect the Future Development of the Infant, Which May be Born at Full Term, Without Manifest Evidence of Congenital Debility. -- The future development of this class of cases is dependent upon their freedom from congenital infection, their protection against postnatal infection and their general resistance.

Symptoms. -- Clinical data of tuberculosis of the new-born premature or full term are so scant that no conclusions can be drawn as to the symptomatology. The combination of enlargement of the spleen, high, irregular temperature and enlargement of the liver, together with tuberculosis in the mother is very suggestive. The infants are usually below weight at birth, pallid and may show a positive tuberculin reaction in the sixth to seventh week of life.

Treatment. -- It is, of course, of the utmost importance that very careful hygienic and dietetic measures be instituted at the earliest opportunity. There are no specific cures or worth-while medicinal measures. The critical question is that of the advisability of nursing.

In general nursing should under all circumstances be forbidden in open pulmonary tuberculosis of the mother, and the same is advisable also in every active tuberculosis. The prohibition of nursing in these cases has for its purpose the removal of the infant from the coughing mother -- from the tuberculous environment -- and is done more because of the danger of inhalation tuberculosis than because of the possibility of an eventual transmission of the bacilli by the mother's milk. Marked tuberculosis of the mother should in all events be a contraindication against nursing for the benefit of both. In such a case it is the duty of the physician to do all in his power to accomplish the removal of the infant from the neighborhood of the mother as soon as possible, at least for the first months of life.

In the cases of mothers proven to be tuberculous, who show no manifest signs at the time of delivery and lactation, caution is necessary. When the removal of the infant from the mother encounters insurmountable opposition and the infant must remain at home, then it is more advisable in such cases not to endanger the infant any more by introducing artificial feeding but to put it to the breast. If in the mother there are neither clinically nor physically demonstrable tuberculous changes, and sputum examination is negative, and if the tuberculosis is not only latent, but also inactive and confined to mild apex findings, then, when the infant remains with the mother, nursing should not only be recommended but strongly urged. If feeding by a wet-nurse is possible it is for all events and purposes the best method in doubtful cases. This should in justice to the wet-nurse be carried out by hand-feeding of expressed milk. The wet-nurse should not come in contact with the infected infant.

Footnotes

[1] Heredity in Tuberculosis, Arch. de méd. des enf., 1915, 18, 1.

[2] Le Prémature de Mère tuberculeuse, Lyon méd., 1911, 116, 72.

[3] Ueber intra-uterine miliare tuberculose, Wien. klin. Wchnschr., 1913, No. 31, 26, 1274-1275.

[4] Congenital Tuberculosis, Jahrb. f. Kinderh., 1913, No. 1, 67, 95.

[5] Tuberculosis as a Disease of the New Born, Am Jour. Dis. Child, 1915, 9, 322.

[6] Contribution to Placental and Congenital Tuberculosis, Beiträge z. Geburtsh. u. Gynäk., 1909-1910, vol. 5.

[7] Congenital Tuberculosis, Berl. klin. Wchnschr., 1912, 19, 877.


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Created 5/19/97 / Last modified 5/20/97
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