A rare congenital tuberculous lymphadenitis in a preterm neonate born to a comatose mother in a high-TB-burden setting: a case report

Background : Congenital tuberculosis (TB) is rare, accounting for <2% of pediatric TB cases, and poses diagnostic challenges in preterm neonates, particularly in high-burden settings like the Democratic Republic of Congo (DRC). Maternal comorbidities, such as critical illness during pregnancy, further complicate timely diagnosis and increase vertical transmission risks. Case Presentation : A preterm male neonate (gestational age: 30 weeks) was born vaginally to a 30-year-old HIV negative comatose mother in the DRC after a pregnancy complicated by a 2-month maternal coma of undetermined etiology. The infant presented with cervical lymphadenopathy, respiratory distress, and failure to thrive. Postpartum, the mother tested positive for pulmonary TB (sputum AFB). Neonatal submandibular lymph node fistulized and biopsy revealed caseating granulomas and tested GeneXpert MTB/RIF-positive. TB-PCR for confirmation of Mycobacterium tuberculosis was not done due to unavailability in the health facility. The infant received weight-adjusted antitubercular therapy (ATT: rifampicin, isoniazid, pyrazinamide) with gradual clinical improvement. Conclusion : This case underscores congenital TB as a critical differential diagnosis in preterm neonates with lymphadenopathy born to mothers with severe antenatal illness in TB-endemic regions. Maternal coma likely delayed TB diagnosis, exacerbating transmission risk. The report highlights the urgent need for integrating TB screening into antenatal care protocols for critically ill pregnant women in high-burden settings, even in the absence of overt TB symptoms. Early maternal diagnosis and neonatal ATT initiation are vital to reducing mortality in this vulnerable population.