Sonographic diagnosis of congenital tuberculosis: an experience with four cases S. B. Grover, 1 D. K. Taneja, 2 A. Bhatia, 1 H. Chellani 2 1 Department of Radiology and Imaging, Safdarjang Hospital, New Delhi 110029, India 2 Department of Pediatric Medicine, Safdarjang Hospital, New Delhi 110029, India Received: 8 March 2000/Accepted: 19 April 2000 Abstract Abdominal sonography of four infants with pyrexia and hepatomegaly demonstrated multiple hypoechoeic he- patic and splenic foci, guided biopsies of which showed caseating granulomas with acid-fast bacilli. Evidence of tuberculosis in maternal endometrium and its exclusion in the contacts further confirmed a diagnosis of congenital tuberculosis. Clinical suspicion supplemented by careful sonography facilitated early detection and antemortem diagnosis of this potentially fatal disease. Key words: Sonography—Hepatomegaly—Caseating granuloma—Acid-fast bacilli—Congenital tuberculosis. Congenital tuberculosis is a rare disease. Although ap- proximately 300 cases have been reported in the world literature, the majority of these are isolated case reports [1– 4]. A high mortality exists for this entity even in the modern chemotherapeutic era, and the diagnosis has been established only at autopsy, even in recent years [5–7]. The delay in diagnosis of congenital tuberculosis is caused by different factors including nonspecific symp- toms that simulate other congenital infections, nonreac- tivity of the Mantoux test even in infected neonates, and the necessity of aspirates and biopsies from body fluids and tissues to establish the diagnosis [1, 2, 8]. The asymp- tomatic status of infected mothers at the time of delivery further confounds the situation [2]. Respiratory distress and hepatomegaly are the leading clinical manifestations of congenital tuberculosis [1, 8]. Although other investigators, namely Matthai et al. [3] and Foo et al. [5], have performed abdominal sonography in their cases of congenital tuberculosis with hepatomeg- aly, the utility of ultrasound as a diagnostic modality has not been emphasized. We highlight the role of sonogra- phy as a primary diagnostic modality for congenital tu- berculosis based on our experience in four infants with hepatomegaly. Case reports Case 1 A 6-week-old male infant presented with a history of intermittent low-grade fever, irritability, poor weight gain, and abdominal distention since birth. Hepatosplenomegaly and pallor were present. The Mantoux test was negative. Gastric aspirate for AFB was negative. The infant’s chest radiograph was normal. Ultrasound of the liver showed multiple hypoechoeic lesions of 1 to 2 cm in both hepatic lobes (Fig. 1A) and spleen (Fig. 1B) and was confirmed by computed tomog- raphy (CT) (Fig. 1C). Ultrasound-guided biopsy from one of the hepatic lesions showed caseating granulomas and acid-fast bacilli. The maternal chest radiograph and of all the contacts was normal, but the maternal endometrial biopsy was positive for tubercular endometritis. Infant and mother were given a full course of antitubercular treatment and had satisfactory recovery. They remained in follow-up for 18 months and are doing well. Case 2 A 3-week-old male infant presented with abdominal distention, poor feeding, poor weight gain, and intermittent fever since birth. The infant had developed respiratory distress and multiple pustular skin lesions over the limbs and abdomen during the preceding week. On examina- tion, cervical, axillary, and inguinal lymph nodes were enlarged, and hepatosplenomegaly was present. The Mantoux test was negative, and the gastric aspirate, cervical lymph node aspirate, and aspiration of skin lesions showed acid-fast bacilli. The chest radiograph showed bilateral miliary mottling. Abdominal sonography showed multiple scattered hypoechoeic 5–10-mm lesions in both hepatic lobes (Fig. 2) and the spleen. Sonographically guided percutaneous needle biopsy from one of Correspondence to: S. B. Grover, E-81, Kalkaji, New Delhi 110019, India Abdom Imaging 25:622– 626 (2000) DOI: 10.1007/s002610000071 Abdominal Imaging © Springer-Verlag New York Inc. 2000