Disseminated tuberculosis is a mycobacterial infection that either involves the blood, bone marrow, liver or two or more noncontiguous sites. While tuberculosis is not uncommon in pregnancy, active, disseminated tuberculosis is exceedingly rare and is associated with poor maternal and fetal outcomes including a ninefold increase in miscarriage. Symptoms of both disseminated tuberculosis in pregnancy can be vague and nonspecific making it difficult to diagnosis. A 20-year-old, immune competent female presented with worsening dyspnea over two months and cavitary lesions on chest imaging. She had been treated with oral antibiotics two months prior and was noted to have an early intrauterine pregnancy at the time. She subsequently miscarried spontaneously. PCR (polymerase chain reaction) testing from brochoalveolar lavage isolated Mycobacterium Tuberculosis. A liquid biopsy (Karius) was positive for Cytomegalovirus, Herpes Simplex Virus 1, and Candida Albicans. The patient had a prolonged and complicated treatment course and ultimately was discharged to inpatient rehabilitation. Disseminated tuberculosis is associated with significant mortality and morbidity warranting prompt treatment with clinical suspicion. Treatment should start when active TB is diagnosed in pregnancy regardless of the trimester. The prenatal care giver is in a unique position to screen and support women who otherwise may not interact with a structured healthcare system.

INTRODUCTION:Diagnosis of disseminated tuberculosis can be challenging, as symptoms can vary significantly and mimic other pathologies (1). Despite being rarely seen in pregnant or post-partum females, its high mortality and morbidity warrant prompt diagnosis and treatment with high clinical suspicion. CASE PRESENTATION:The patient is a 20-year-old female with past medical history of recent spontaneous abortion who presented with progressive dyspnea treated with antibiotics 2 months prior. Upon presentation, patient was hemodynamically stable with a GCS of 14. In the hours following admission, she decompensated quickly requiring intubation and vasopressors. CT chest revealed several bilateral cavitary lesions, the largest in the left upper lobe measuring 3.8 x 4.1cm. Transthoracic echocardiogram revealed an ejection fraction of 15-19% and left ventricular thrombosis. Bronchoscopy was preformed, resulting in Mycobacterium Tuberculosis (MTB) on PCR. Treatment was initiated with rifabutin, levofloxacin, pyrazinamide, ursodiol, and solumedrol. HIV was negative. Karius test was positive for cytomegalovirus, herpes simplex virus 1, MTB, and Candida albicans. Micafungin and valganciclovir were added to the treatment regimen. The patient's course was complicated requiring tracheostomy, multiple limb amputations, and extended ICU stay. The patient's condition slowly stabilized and she is currently pending discharge to a long-term care facility.DISCUSSION: In 2011, there were estimated to be more than 200,000 cases of active TB in pregnant females across the globe. While tuberculosis can be prevalent in pregnancy, the progressive disseminated hematogenous form is rare (1). Disseminated tuberculosis is a mycobacterial infection that either involves the blood, bone marrow, or liver; or involves two or more noncontiguous sites. Symptoms can vary significantly and resemble a variety of other pathologies (2). Less often, patients can present with acute respiratory failure, cholangitis, and hypotension (1). As the mortality of disseminated tuberculosis increases significantly with delay in treatment, a high clinical suspicion is required, particularly in countries where prevalence of TB is lower (2).The body's defense against tuberculosis is a cellular immune response. A physiological change in pregnancy results in the suppression of the T-helper 1 cells and has been thought to increase susceptibility to infection, reactivation, and spread of tuberculosis. After delivery, there is no suppression of the T-helper 1 cells and symptoms of tuberculosis can be exacerbated. It is hypothesized that after our patient's spontaneous abortion, the cellular immune response was reactivated and resulted in a proinflammatory response (1). CONCLUSIONS: Our case highlights the importance of considering disseminated tuberculosis as a differential in a post-partum patient presenting with respiratory symptoms with cavitary lesions.