Gastrointestinal-Initiated Disseminated Tuberculosis in 3rd Trimester: ECMO Rescue via Metagenomics

Introduction: Peripartum TB increases fatal disseminated disease risk due to immunosuppression and diagnostic delays, contributing to maternal mortality. We report a near-fatal case presenting atypically with GI symptoms mimicking food poisoning. It rapidly progressed to postpartum refractory ARDS but was saved by synergistic mNGS diagnosis and prolonged VV-ECMO, highlighting diagnostic challenges, therapeutic complexity, and these technologies' life-saving potential.


Description: A 30-year-old primigravida at 31⁺² weeks presented with 23 days of watery diarrhea and low-grade fever. Upon transfer for vaginal bleeding, she spontaneously delivered. She acutely developed high fever, chills, dyspnea, and refractory hypoxemia (SpO₂ 70%) postpartum, requiring ICU admission. Evaluation revealed severe Type II respiratory failure, marked inflammation, anemia, lymphopenia, and bilateral infiltrates on CXR. Despite escalating oxygen support and broad-spectrum antibiotics, she deteriorated catastrophically (SpO₂ 55%), requiring intubation. BAL and blood mNGS identified heavy M. tuberculosis complex burden (36,930 reads). Quadruple anti-TB therapy was started. Echocardiography showed RV dysfunction ("D-sign"), prompting VV-ECMO initiation for refractory ARDS. Placental pathology showed acute chorioamnionitis without TB features.


Discussion: Pregnancy-associated tuberculosis presents diagnostic challenges due to atypical symptoms, immune masking during gestation, and imaging limitations. Postpartum immunological changes triggered ARDS resembling IRIS. BAL-metagenomic NGS rapidly detected TB when conventional methods failed, enabling critical intervention. Concurrent MDR Klebsiella infection, amplified by TB immunosuppression, complicated care. VV-ECMO salvaged TB-associated ARDS with cardiorespiratory failure, but systemic anticoagulation caused life-threatening hemorrhage exacerbated by peripartum hypercoagulability. While active TB increased maternal morbidity, no vertical transmission occurred. This case highlights peripartum TB as an occult, rapidly progressive critical illness requiring heightened suspicion in endemic areas, with key insights including BAL-mNGS for transformative diagnosis, VV-ECMO as salvage therapy demanding vigilant monitoring, and multidisciplinary long-term care.