INTRODUCTION

Congenital tuberculosis (TB) refers to an infection due to contact between the baby and the TB bacillus in the uterus or during delivery. Maternal TB can be transmitted to the fetus through the placenta or by inhalation of infected amniotic fluid. The former forms primary complexes in the liver of infants, and the latter forms primary lesions in the lungs or gastrointestinal tract[1]. Congenital TB is very rare, and the mortality rate is exceptionally high[2,3]. Respiratory failure is the most common cause of death[2,4,5]. Intracranial infection is one of the most severe complications, seriously affecting the prognosis[3]. Misdiagnosis and untimely treatment are the main reasons for aggravation of the condition. Situs inversus totalis (SIT) is a rare congenital malformation, and some patients may also suffer from defective ciliary motility[6]. The ciliary immobility is involved in the absence of mucociliary transport in the respiratory epithelia[7], which may induce lung infections. We here report a patient who suffered from rare congenital TB, tuberculous meningitis, and SIT. Congenital TB complicated with SIT was not found from the Google Scholar and PubMed databases.

CASE PRESENTATION

Chief complaints

A 19-day-old male newborn was admitted to the hospital with a fever for 6 h.

History of present illness

The child was born at 41 wk of gestation and was delivered smoothly. The birth weight was 2.925 kg. His respiratory rate was 50 breaths/min, weight was 3.93 kg, heart rate was 150 beats/min, and he had no intrauterine distress and no premature rupture of fetal membranes. Fever occurred 6 h before admission, and the highest body temperature was 38.2 ℃.

History of past illness

The baby was delivered normally without a history of allergies.

Personal and family history

The patient’s mother had a history of miscarriage. Both parents denied a history of TB, but his grandmother had TB when she was young.

Physical examination

Lin H, a radiologist, reviewed the literature, participated in the drafting of the manuscript, and interpreted the imaging findings; Teng S and Wang Z reviewed the literature and contributed to manuscript drafting; Liu QY was responsible for the revision of the manuscript for important intellectual content; all authors issued final approval for the version to be submitted.

記者經(jīng)過樓上活動室時，看到有兩位老人正在打乒乓球，看上去身體很硬朗，濟南恒協(xié)基愛社區(qū)養(yǎng)老服務中心主任、山東恒協(xié)基愛老年產(chǎn)業(yè)投資有限公司公司董事長張振美告訴記者，孫叔和趙叔是老人中身體最好的兩位，最愛鍛煉，乒乓球室和健身房常被他們倆“霸占”著。

Laboratory examinations

The following parameters were observed in serum: C-reactive protein 46.3 mg/L (reference range: ≤ 6.0 mg/L), procalcitonin 1.23 μg/L (reference range: < 0.054 μg/L), white blood cells (WBC) 22.92 × 10

/L (reference range: 15-20 × 10

/L), neutrophils 0.701, total bilirubin 87.9 μmol/L (reference range: < 26.0 μmol/L), and indirect bilirubin 81.2 μmol/L (reference range: < 14.0 μmol/L). Cerebrospinal fluid (CSF) was cloudy, with a chloride ion level of 117.5 mmol/L (reference range: 120.0-132.0 mmol/L), protein concentration 0.92 g/L (reference range: 0.08-0.43 g/L), glucose 3.15 mmol/L (reference range: 3.9-5.0 mmol/L), adenosine deaminase 0.2 U/L, and WBC 35 × 10

/L (reference range: < 30 × 10

/L). Bacterial testing showed Gram-positive cocci on smears, acid-fast bacilli were found on acid-fast staining, and the tuberculin-γ-interferon release test was positive. Microbial genetic testing detected the

complex.

Imaging examinations

The imaging manifestations of congenital TB have specific characteristics. Early imaging of lesions may include interstitial pneumonia[12], and miliary pneumonia and multiple pulmonary nodules may appear when the condition worsens. Multiple pulmonary nodules are considered disease progression[12]. Peng

[3] suggested that miliary TB on chest imaging 4 wk postpartum should be used as one of the diagnostic criteria for congenital TB, which can provide a timely basis for diagnosis and treatment. If

spreads to the liver and spleen

the blood, it can form a primary complex. Abdominal CT showed hepatosplenomegaly, and multiple low-density primary complexes were also seen. In our case, the baby's chest radiography and chest CT showed scattered high-density nodules in both lungs, thickened lung texture, enlarged hilar lymph nodes, and normal size and density of the liver and spleen. In addition, the dextrocardia and internal organs were reversed (Figures 1 and 2). Therefore, we believe that the cause in this case was the infant inhaling or ingesting amniotic fluid contaminated by

.

FINAL DIAGNOSIS

The baby was finally diagnosed with congenital TB with tuberculous meningitis and SIT.

The mortality rate of congenital TB is very high, close to 50%, usually due to delayed diagnosis and treatment[5]. The clinical manifestations do not improve after antibiotic treatment, and the condition of 96% of children may worsen[3]. Early diagnosis and timely anti-TB treatment can significantly reduce infant mortality and improve prognosis[3]. Newborns with congenital TB should receive isoniazid (10-15 mg/kg/d), rifampicin (10-20 mg/kg/d), pyrazinamide (20-40 mg/kg/d), and streptomycin (20-40 mg/kg/d) intravenously for 2 mo; isoniazid and rifampicin should be continued for 6 mo[25]. Our patient only started anti-TB treatment on the 10

day after admission, but his condition continued to deteriorate, and he eventually developed severe pneumonia and tuberculous meningitis and died of respiratory failure at 38 d.

TREATMENT

Following admission, the patient underwent repeated tests for viruses and bacteria, including

and other pathogens. The test samples included blood, sputum, gastric juice, and CSF. The test results in the first 10 d were all negative. Amoxicillin and clavulanate potassium were given on the day of admission. Potassium retinoic acid (0.117 g IV q8h) was discontinued the next day and changed to oseltamivir phosphate granules (10 mg oral qd) and ceftazidime (0.19 g IV q8h). Vancomycin (58 mg IV q8h) was administered and the blood concentration of vancomycin was controlled at 7.4 μg/mL (effective range: 7-10 μg/mL). Meropenem (0.15 g IV q8h) was added on the 4

day after admission. However, these anti-infective treatments were ineffective, lung exudation was aggravated, and regular blood oxygen saturation could not be maintained. Invasive ventilation was then used to support the patient's breathing. Neurological symptoms such as epilepsy and irritability were also observed. On the 10

day after admission, acid-fast bacilli were found in the patient's sputum following acid-fast staining. Microbial genetic tests confirmed

complex. Vancomycin, oseltamivir phosphate particles, and ceftazidime were then stopped, and anti-TB treatment was started with niacin injection (0.057 g IV qd), pyrazinamide tablets (0.13 g gastric tube injection qd), and rifampicin injection (0.057 g IV qd). After 7 d of anti-TB treatment, the patient's chest radiography showed improvement in lung exudation (Figure 1). The child was kept alive through invasive ventilation, but eventually died of respiratory failure due to the worsening of the disease.

OUTCOME AND FOLLOW-UP

電池在過充到一定階段，電池內(nèi)壓過大超過電池蓋板與殼體之間的焊接強度時就會發(fā)生破裂，隨后電池內(nèi)部的高壓氣液混合物就會噴出，在噴射過程中遇到氧氣，并與空氣、電池測試支架摩擦，就會發(fā)生爆炸。圖2是電池2C過充致爆過程中噴射物的紅外熱像圖片。

DISCUSSION

Congenital TB is a rare disease. In 2005, fewer than 376 cases were reported worldwide[2]. Cantwell

[1] proposed the classic diagnostic criteria for congenital TB, where infants were confirmed to have TB if they had at least one of the followings: Symptoms in the first week after birth, primary liver TB complex, maternal genital tract or placental TB, and postpartum transmission ruled out by thorough investigation of contacts. In this case, the mother's tuberculin skin test was positive, and pelvic CT suggested possible tuberculous peritonitis. Moreover,

was found in the baby's sputum, and chest radiography indicated progressive and disseminated TB. Therefore, our case met these diagnostic criteria.

The clinical manifestations of congenital TB are non-specific, making early diagnosis difficult[1,5]. The most common clinical symptoms are loss of appetite, fever, restlessness, hypoplasia, weight loss, cough, respiratory distress, hepatosplenomegaly, splenomegaly, lymphadenopathy, and abdominal distension[2,8]. Generally, congenital TB is easily misdiagnosed as pneumonia, sepsis, and purulent meningitis[3]. Conventional antibiotic treatment is ineffective and the disease may progress to serious complications such as miliary TB and tuberculous meningitis. These serious complications may be related to the infant's immature innate immunity[9]. The clinical symptoms of the child, in this case, were mainly fever, loss of appetite, restlessness, and respiratory distress. These symptoms are nonspecific.

was not detected in the baby in the first 10 d after admission. The mother had no symptoms of TB infection before and after childbirth. Therefore, TB infection could not be diagnosed early.

Laboratory tests for congenital TB are generally non-characteristic and easily confused with acute infections due to other pathogens[10]. The most common reaction is an increase in the number of WBC and inflammatory indicators. Identifying the presence of tubercle bacilli by fluid body cultures, acid-fast staining, or tissue biopsy is the gold standard for the diagnosis of TB[11]. In our case, bacteria and viruses were tested immediately after admission, and the results were negative. In addition, repeated acid-fast staining of sputum and gastric juice was negative, and tubercle bacilli were not found in the sputum until the 10

day after admission. Delayed diagnosis is a crucial cause of disease aggravation.

所遞交的檢測流程和結(jié)果報告要以書面形式展現(xiàn)，要求環(huán)境監(jiān)測在日常工作中把責任內(nèi)容分配到每個人身上，把審核制度分成三級：（1）原始采樣審核制度；（2）分析原始記錄審核制度；（3）報告審核制度。構(gòu)建完成后，需加大監(jiān)管審核力度。提高環(huán)境監(jiān)測的質(zhì)量，是當前環(huán)境監(jiān)測機構(gòu)的重點內(nèi)容。環(huán)境監(jiān)測的水平與科學化程度對環(huán)境監(jiān)測質(zhì)量有很大的影響，所以，要通過制度的約束來提高環(huán)境監(jiān)測的質(zhì)量。

Chest radiography showed increased texture and thickening of the lungs, scattered with patchy highdensity shadows. In addition, the apex of the heart and gastric bobble was on the right, and the liver was on the left (Figure 1). Chest computed tomography (CT) showed multiple nodules in both lungs, and hilar lymph nodes were enlarged (Figure 2A and B). The heart, liver, and spleen were also completely reversed, showing mirror-like changes (Figure 2B and C).

經(jīng)過對檢測段周圍水文地質(zhì)情況的勘察，發(fā)現(xiàn)其進口處的圍巖主要是灰色凝灰?guī)r，但是其中夾雜一些夾凝灰質(zhì)砂頁巖，這種巖石的塊狀結(jié)構(gòu)比較大，且比較完整，但是其抗風化的能力比較弱。而周圍的地下水來源主要是地表水和雨水的滲透，因此，受到季節(jié)的影響比較大。進行施工時，缺陷段的圍巖沒有出現(xiàn)滲漏水的現(xiàn)象[1]。而在斜井周圍，2個方向的水文地質(zhì)情況也不相同，雖然周圍的巖石都是凝灰?guī)r，但是小里程方向段的圍巖質(zhì)量明顯比大里程方向段的好。二者的地下水情況基本相似，都是靠雨水和地表水作為補給源，受季節(jié)的影響變化較大。同時，在施工過程中也沒有出現(xiàn)滲漏水現(xiàn)象。

2.1.2 采集地點。調(diào)查地點為河北省懷安縣太平莊鄉(xiāng)、陽原縣大田洼鄉(xiāng)。其土壤為北方典型的干旱半干旱貧瘠類型。河北省懷安縣太平莊鄉(xiāng)屬高寒山區(qū)與丘陵區(qū)，耕地2 323 hm2，旱地2 306 hm2，旱地占比99.3%。陽原縣大田洼鄉(xiāng)耕地1 043 hm2，旱地面積705 hm2，旱地占比67.6%。

Inborn anomalies of organ placement are rare developmental abnormalities with an incidence of about 1/8000[21], which can be divided into SIT and incomplete situs inversus[22]. However, in 20%-25% of SIT cases, they also have Kartagener syndrome (KS) (bronchial immobility, bronchiectasis, chronic sinusitis, and male infertility)[23,24]. KS is also known as ciliary immobility syndrome, which can lead to obstruction of mucus drainage from the respiratory tract, which increases the possibility of lung infection. However, we cannot confirm whether the baby has KS and whether KS will increase the prevalence of congenital TB.

13號線推薦采用最高運行速度為100 km/h的列車。當列車過站速度為100 km/h時，在不同的站間距條件下，快車少停1站所節(jié)約的時間約為25～30 s。另外，考慮在城市軌道交通中，平均停站時間為30～35 s。綜上所述，13號線快車若少停1站，可節(jié)省時間55～65 s。

The newborn underwent anti-TB treatment, but due to delays in diagnosis and treatment, his condition continued to deteriorate and he eventually developed severe pneumonia and tuberculous meningitis, and died of respiratory failure at 38 d.

CONCLUSION

Congenital TB is very rare, and concurrent tuberculous meningitis and congenital SIT have not been reported. It is not clear whether they are related or not. The clinical manifestations of congenital TB are non-specific, the detection of pathogenic bacteria is difficult, it is easily misdiagnosed, the fatality rate of the disease is high, and it can progress to severe tuberculous meningitis. Early diagnosis and anti-TB treatment are the keys to reducing mortality and improving infant prognosis. For infants with a high suspicion of TB infection, empirical anti-TB treatment should be administered.

作為現(xiàn)實社會的延伸，網(wǎng)絡空間也同樣充滿了各國之間的分歧和沖突。個別西方國家依靠自己的網(wǎng)絡技術優(yōu)勢，壟斷網(wǎng)絡資源和網(wǎng)絡話語權，實施網(wǎng)絡霸權。某些西方發(fā)達國家為了懲罰或推翻非親西方的發(fā)展中國家，往往會以切斷其國家的網(wǎng)絡服務為借口進行要挾，逼迫發(fā)展中國家就范；或者利用網(wǎng)絡空間對于發(fā)展中國家進行意識形態(tài)滲透，造成社會的混亂；更有甚者直接利用網(wǎng)絡工具煽動和策劃發(fā)展中國家內(nèi)部的反政府力量進行推翻現(xiàn)有政府的活動。這些活動必然會加深發(fā)展中國家與這些發(fā)達國家之間關于網(wǎng)絡規(guī)則、網(wǎng)絡秩序和網(wǎng)絡治理理念的分歧與對抗。

FOOTNOTES

Breath sounds were rough in both lungs, with an increased breathing rate and wet rales could be heard.

In recent decades, neonatal tuberculous meningitis has rarely been reported[13-15]. Common neurological symptoms and signs include drowsiness, meningeal irritation, cranial nerve palsy, epilepsy, hemiplegia, alteration of consciousness, coma,

[16]. About half of all tuberculous meningitis infections cause severe disability or death[17]. When TB meningitis is suspected, magnetic resonance imaging (MRI) should be selected, as it is unique in assessing early and late disease and is effective in children with suspected TB meningitis[18,19]. In this case, the infant's neurological symptoms were irritability, convulsions, and poor response. The number of WBCs and protein concentrations in the CSF were increased, and the concentrations of glucose and chloride ions were decreased. Combined with the detection of TB and multiple pulmonary nodules following sputum analysis, this was consistent with the diagnostic criteria for tuberculous meningitis[20]. Unfortunately, head MRI was not performed at that time.

Informed written consent was obtained from the patient for publication of this report and any accompanying images.

No conflicting relationship exists for any author.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

但自從有了這些電子產(chǎn)品，許多帶給我的很多惹我焦慮的事物倒不再是問題了。比如從前每次開會，聽人念報告，我都有大聲唱歌的沖動，就像在大合唱的時候很想放聲尖叫。而現(xiàn)在，當別的同事掏出本子，我會默默地打開Kindle，反正Kindle的保護殼和開會用的黑皮本很像。再比如家長會，一聽見那個分貝大、底氣足、語氣堅定、音色尖銳的校長在廣播里講著不容置疑的道理，我渾身的神經(jīng)元細胞都緊張起來——好在有手機。

China

Hu Lin 0000-0003-2365-8254; Shuang Teng 0000-0002-4074-4026; Zhong Wang 0000-0002-6391-9140; Qi-Yu Liu 0000-0002-8166-3134.

Fan JR

為推進生態(tài)旅游治理提供有力執(zhí)法和司法保障。用嚴格的法律制度引領生態(tài)旅游治理措施，保護生態(tài)環(huán)境，為推進生態(tài)旅游治理的實施提供執(zhí)法和司法保障。首先，加大執(zhí)法力度，對干擾管理活動、破壞生態(tài)環(huán)境的行為要給予嚴厲打擊。其次，細化和完善現(xiàn)有環(huán)境侵權責任法律制度，引導社區(qū)居民利用法律武器保護自身生態(tài)權益。再次，加大對破壞生態(tài)、妨礙治理行為的法律責任追究力度，對損害生態(tài)環(huán)境的惡劣行為給予嚴厲制裁。

Wang TQ

Fan JR

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