Tuberculous osteomyelitis in pregnancy during the COVID 19 pandemic: A rare case report with a catastrophic result
AUTHORS:
Judith Perez Peralta, M.D., FPOGS, FPIDSOG
Quirino Memorial Medical Center, Philippines
St. Luke's Medical Center Global City, Philippines

Gretchen L. Tizo, M.D.
Quirino Memorial Medical Center, Philippines

Introduction:
Global statistics show that tuberculosis (TB) is one of the 5 top killers of women between the ages of 20-59 and an estimated quarter of a million pregnant women have active TB. Maternal death due to TB accounts for 15-30% of the indirect maternal death. Tuberculous osteomyelitis is mainly due to the lymphohematogenous spread of Mycobacterium tuberculosis from the pulmonary focus. A rare representation of this disease entity is metacarpal involvement which represents only 1% of cases. There is no locally available data on the incidence of tuberculosis in pregnancy.

Objectives:
To present a rare case of Tuberculous Osteomyelitis in pregnancy with catastrophic sequelae during the COVID 19 pandemic. To present initial local data to describe the pandemic’s impact on the diagnosis, treatment and surveillance of tuberculosis in pregnancy.

Methodology:
This is a case study of a 23 year old Filipino, primigravid with a 5- month history of under-treated Pulmonary Tuberculosis (PTB). She also had a 1-month history of a small nodule on the left index finger that increased in size, tenderness swelling and pain, initially managed as cellulitis and given clindamycin for 2 weeks with no resolution. One month later, the lesion ruptured with white-yellowish drainage. At the ER, hand X-ray revealed 2nd metacarpal osteomyelitis with pathologic fracture and she was advised admission for Ray amputation. She refused due to lack of family and financial support but promised to follow up. However, due to the community lockdown, she was unable to continue PTB treatment or follow up until she consulted at term for labor pains and was admitted for delivery and postpartum Ray amputation. TB osteomyelitis was confirmed by histopathological diagnosis. Hospital census and scientific literature were reviewed tor the incidence rates of TB osteomyelitis and TB in pregnancy since the pandemic.

RESULTS

TB management was delayed by months leading to amputation in an obstetric patient, a preventable catastrophic result brought about by the pandemic lockdown. Hospital census revealed that there were 114 new cases or 19 cases per month of PTB in pregnancy from April to October 2020 compared to an average of one reported case per month during January to March 2020. Review of census showed an increase in case identification through incidental findings from compulsory chest radiography upon admission. Since COVID RT PCR testing was not readily available upon admission, chest X-ray with abdominal shield for all pregnant patients was requested for rapid classification of patients as COVID suspects. Review of literature revealed an initial report by stating that there was a decrease in TB consultations during the pandemic.

CONCLUSION
The pandemic caused a delay in diagnosis, treatment and surveillance of TB osteomyelitis, leading to grave morbidity like amputation and possible death if left unattended. TB osteomyelitis requires a high index of suspicion for accurate and timely diagnosis and initiation of treatment. There was increased case finding due to compulsory chest X-rays to screen for COVID-19 in pregnancy. This observation was supported by review of literature showing a decrease in consultations for TB due to the pandemic lockdown.

RECOMMENDATION
The authors recommend further studies on the benefits and effects of TB screening using shielded chest radiography during routine prenatal care in populations endemic for tuberculosis. During a pandemic, additional efforts are needed to improve and maintain referral systems to government agencies for coordinated continuity of care outside hospital settings. It is also crucial to continue follow up regarding TB drug side effects and toxicity and life-threatening sequelae like tuberculous osteomyelitis in pregnancy.

Keywords: Tuberculosis; Tuberous Osteomyelitis, Pregnancy, COVID-19, coronavirus

Judith Perez Peralta MD

Quirino Memorial Medical Center

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