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Tuberculous osteomyelitis in pregnancy during the COVID 19 pandemic: A rare case report with a catastrophic result

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 a 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 tuberculous osteomyelitis  in pregnancy.

Objectives:

To present a rare case of Tuberculous Osteomyelitis in pregnancy with catastrophic sequelae leading to Ray amputation of the left pointer finger 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 primigravida who was diagnosed 5 months prior to admission with hypothyroidism and bilateral Pulmonary Tuberculosis (PTB). Treatment was delayed and discontinued due to inaccessibility caused by the community lockdown. One month prior to admission,  a small nodule was noted on the left index finger, increasing  in size, tenderness swelling and pain over 2 weeks. She was initially managed as cellulitis and given clindamycin for 2 weeks with no resolution. Another  month later, the lesion ruptured with yellowish-white 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 and promised to follow-up but was prevented by the community quarantine. Severe pain and limited range of motion worsened for 2 more weeks 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 before and after 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. OB-Gyn department census revealed a decrease in pelvic TB from 2017 to Oct 2020.  However, there was scarce data on pulmonary TB in obstetric patients because chest X-ray is not routine in prenatal care.

During the pandemic, there were 147 new cases of PTB in pregnancy. The average number of new cases increased from 1.6 cases per month during Jan-March 2020  ( pre- pandemic ) to 21 cases per month  during April to October 2020 (pandemic.) 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 19 suspects. 

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 of PTB in pregnancy due to compulsory chest X-rays to screen for COVID-19 in pregnancy however these cases need  verification  .

RECOMMENDATION

The authors recommend further studies on the incidence and prevalence rates of tuberculosis in pregnancy. Also, conduct  studies on the value of shielded chest radiography during routine prenatal care in screening  for PTB 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 treatment and surveillance of TB for drug side effects, toxicity and life-threatening sequelae like tuberculous osteomyelitis in pregnancy. 

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