Tuberculosis (TB) has been increasingly reported and is a major public health problem in Malaysia. It remains the top 10 causes of death worldwide. This is also a potentially treatable and preventable indirect cause of maternal death. We report a case of postpartum pulmonary TB with extrapulmonary spread, and how a correct diagnosis of TB and appropriate management can improve the outcome.

A 23-year-old lady, presented to the primary health care clinic within 2 weeks post-partum period with history of fever for 2 weeks, associated with productive cough and suprapubic pain. She was initially treated as community acquired pneumonia but her condition deteriorated despite of antibiotics treatment. She was referred to our centre for severe pneumonia with impending respiratory collapse. Upon assessment, she was tachypnoeic, tachycardia but afebrile. Lung auscultation revealed generalized rhonchi and crepitation bilaterally. Uterus was just palpable with ascites present on abdominal examination. Speculum and vaginal examination was unremarkable. She needed intubation and required intensive care unit admission. Chest x-ray imaging revealed pleural effusion which needed a chest tube drainage insertion. Her sputum was positive for acid fast bacilli (AFB) and culture grew Mycobacterium Tuberculosis. Transabdominal US shown floating uterus with hydrometra seen with bilateral hydrosalpinx. CT abdomen showed findings suggestive of ascending colon tuberculosis with pelvic collections and pyosalpinx. Pipelle sampling showed chronic granulomatous inflammation, most likely due to TB. Further history revealed the patient had been living with her family including with an uncle who had TB and completed treatment 1 year ago. Anti-tuberculosis treatment with isoniazid (H), rifampicin (R), pyrazinamide (Z) and ethambutol (E) was started immediately. She improved markedly and discharged well after 14 days and currently on DOTS under primary health care follow up.

Diagnosis of TB is challenging in pregnant women as the nonspecific constitutional symptoms like malaise and fatigue mimics the physiological changes.  More than half of pregnant women with TB are asymptomatic due to latent infection. Literatures suggested that pregnancy and childbirth may lead to progression of latent infection to active tuberculosis.  Being sputum positive for AFB following delivery, there is a potential risk of transmission infection to the newborn.

This case illustrates the importance of early detection, accurate diagnosis and treatment can potentially minimize adverse patient outcome. A high index of suspicion for TB is needed especially in patients presenting with non-specific symptoms. It also reinforces the need for a complete social history to identify significant exposures of TB patients