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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 206-209

COVID-19 pneumonia with pulmonary tuberculosis: Double trouble


1 Department of Pulmonary Medicine, MIMSR Medical College, Latur, Maharashtra, India
2 Department of Internal Medicine, MIMSR Medical College, Latur, Maharashtra, India

Date of Submission11-Mar-2021
Date of Acceptance14-Mar-2021
Date of Web Publication14-Jun-2021

Correspondence Address:
Shital Patil
Department of Pulmonary Medicine, MIMSR Medical College, Latur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_51_21

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  Abstract 


A 75-year-old male presented with acute febrile respiratory illness with hypoxia and anorexia of longer duration; computed tomography (CT) of the thorax was suggestive of cavitary lung disease, with sputum smear positive for acid-fast bacilli and also having classical COVID-19 pneumonia patterns in the CT thorax; and COVID-19 rapid antigen test was positive. He was treated for COVID-19 pneumonia and antituberculosis treatment was initiated at the discharge. He was recovered of both conditions, and we have documented the crucial role of chest CT in managing this case in this pandemic period.

Keywords: COVID-19, sputum smear acid-fast bacilli positive, tuberculosis


How to cite this article:
Patil S, Gondhali G. COVID-19 pneumonia with pulmonary tuberculosis: Double trouble. Int J Mycobacteriol 2021;10:206-9

How to cite this URL:
Patil S, Gondhali G. COVID-19 pneumonia with pulmonary tuberculosis: Double trouble. Int J Mycobacteriol [serial online] 2021 [cited 2022 Nov 27];10:206-9. Available from: https://www.ijmyco.org/text.asp?2021/10/2/206/318380




  Introduction Top


The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) pandemic has attracted interest because of its global rapid spread, clinical severity, high mortality rate, and capacity to overwhelm healthcare systems.[1] SARS-CoV-2 transmission occurs mainly through droplets, although surface contamination contributes and debate continues on aerosol transmission.[2],[3] Tuberculosis (TB) is a bacterial infection known to humankind for a long time.[4] The disease is a major public health problem especially in the low-income countries of Asia, Africa, and Europe. The disease is caused by Mycobacterium tuberculosis.[5]


  Case Report Top


A 75-year-old male, ex-smoker, presented with anorexia and loss of weight of 6 months duration with intermittent hemoptysis and having acute febrile respiratory illness of <1 week duration of cough with sputum production, high-grade fever, and shortness of breath; he was febrile and hypoxic at room air with oxygen saturation of 84% and heart rate of 126/min. We have documented pallor and cachexia on general examination and on clinical examination during auscultation documented normal air entry on both lung fields with adventitious sounds as bilateral crepitations in lung fields. We have initiated antibiotics with oxygen supplementation by nasal cannula flow at 4 l/min with oxygen saturation target more than 93% and performed chest X-ray initially with blood investigations such as hemogram and liver and kidney functions with viral markers.

Hemogram has documented low lymphocyte count (<6%), high C-reactive protein (CRP) titer, high lactate dehydrogenase (LDH) level, high ferritin level, and high erythrocyte sedimentation rate (ESR). We have also documented high D-dimer levels and high interleukin-6 levels.

Chest X-ray [Figure 1] posterioanterior view showing thick-walled moderate-sized cavity in the left upper zone with in-homogenous infiltrates in the left upper zone with parenchymal infiltrates in the bilateral lower lung fields.
Figure 1: Chest X-ray

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We have sent sputum sample for smear preparation and acid-fast bacilli (AFB) and we have documented AFB in the sputum; further, we have sent sputum for Gene Xpert MTB/RIF and we have documented MTB positive without rpo-b mutation detection.

As chest X-ray was showing in-homogenous opacity in the bilateral lung fields, and during the pandemic period, we have followed protocol and performed computed tomography (CT) of the thorax.

Chest CT of the thorax [Figure 2] and [Figure 3] was suggestive of thick-walled cavity in the left upper lobe with pericavitary satellite nodules and pericavitary consolidations which are characteristic features of active pulmonary TB. Also peripheral pleural-based airspace opacities in the bilateral lung fields, which are classical radiological findings in COVID-19 lung involvement [Figure 2] and [Figure 3].
Figure 2: Chest computed tomography of the thorax

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Figure 3: Chest computed tomography of the thorax

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Chest CT of the thorax was suggestive of patchy consolidations in the bilateral upper and lower lobe lung segments, predominantly affecting sub-pleural region with ground-glass haziness, possibility of COVID-19 infection to be ruled out [Figure 4], [Figure 5], [Figure 6].
Figure 4: Chest computed tomography of the thorax

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Figure 5: Chest computed tomography of the thorax

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Figure 6: Chest computed tomography of the thorax

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We have sent nasopharyngeal and oropharyngeal swabs for COVID-19 qualitative real-time RNA polymerase chain reaction test, and the results of test were positive for RNA specific to SARS-CoV-2.

We have continued antibiotics as per the institutional protocol, anti-TB treatment as per the RNTCP protocol as per weight band containing four drugs namely isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z) and injection remdesivir 200 mg bolus on day 1 followed by 100 mg one time daily for 5 days.

We have also given injection methyl prednisolone 40 mg three times and injection low-molecular-weight heparin for 5 days.

After 1 week of treatment in the intensive care unit, general health was recovered, oxygenation improved with maintaining oxygen saturation more than 96% at room air; and appetite improved, started anti-TB treatment as per weight band, and tolerating with good compliance.

He was discharged to home with advice for strict anti-TB treatment as four drugs in the first 2 months (HRZE) and three drugs in the next 4 months (HRE) as per the RNTCP national guidelines for TB treatment. He was regularly monthly followed for 6 months, clinical and radiological assessment was done, and we have documented weight gain and general health improvement with best compliance to anti-TB treatment.

After 6 months of completion of treatment, we have documented as near-complete clinical and radiological recovery.

Chest X-ray (at 6 months of completion of treatment) showed near-complete radiological resolution in both lung fields with small fibrosis in the left upper lung filed suggestive of healed TB [Figure 7].
Figure 7: Chest x-ray PA at 6 months of completion of treatment

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  Discussion Top


Concomitant TB and COVID-19 cases were not published, and evidence has not been available in the literature from high TB case burden setting like India before our case. Hence, we have studied and followed up completely till the completion of anti-TB treatment. The global spread of COVID-19 has overwhelmed the healthcare systems across all the countries.[6] The rapidly progressing viral infection has resulted in a pandemic which has resulted in large-scale morbidity and mortality.[6] The spread of COVID-19 in countries that have a high burden of other diseases like TB could has a devastating effect on already crumbling health facilities in these low- and middle-income countries.[7] Further, as reported in the past, such pandemics can result in a tendency to overlook other endemic diseases, such as TB.[8] The disease like TB is of a common occurrence, especially in the high-burden countries.[5]

The first report of TB and COVID-19 co-infection was published by He et al., 2020 from China where they reported three cases of the two infections.[9] The present case differs from the three cases of He et al., 2020 by his geographic location, no history of TB in the past or in the family and close contacts, no complaints of diarrhea, and no reinfection to date.[10],[11] However, the study by He et al., 2020 had limitations of not performing CBNAAT (cartridge based nucleic acid amplification tests) and culture of M. tuberculosis, on the study subjects.[9] Thus, a diagnosis of drug-resistant TB in their study could not be established. Our patient had drug-sensitive TB and was thus given appropriate treatment as per the drug sensitivity by four antitubercular drugs. All the set guidelines as detailed in the RNTCP were followed in our case. The present case showed certain similarities with the study of He et al., 2020 in gender, presenting symptoms, and laboratory tests which showed low lymphocyte count, higher than normal levels of CRP, LDH, and ESR.[9]

In the past, the co-infection of TB has been reported in the epidemics and pandemics of other viral diseases such as SARS and MERS.[10],[11] Thus, the possibility of TB with COVID-19 should always be considered in high TB burden settings.

Important clinical clues and lessons from this case report

TB and COVID-19 are rare combinations and always suspect in tropical countries like India where the burden of TB is high, and in the pandemic era, all lung infiltrates should be screened for COVID-19 lung involvement. Hypoxia is rare in TB and is clinical clue to thick more than TB as underlying pathology for hypoxia. CT of the thorax is very crucial and should be performed for typical COVID-19 pathology, as CT is one of the most sensitive tests to pick up earlier lung involvement. High index of suspicion is must while managing cavitary lung disease and timely workup will have successful treatment outcome in this COVID-19 pandemic.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vitacca M, Nava S, Santus P, Harari S. Early consensus management for non-ICU ARF SARS-CoV-2 emergency in Italy: From ward to trenches. Eur Respir J 2020;55:2000632.  Back to cited text no. 1
    
2.
Lewis D. Is the coronavirus airborne? Experts can't agree. Nature 2020;580:175.  Back to cited text no. 2
    
3.
Leung CC, Lam TH, Cheng KK. Let us not forget the mask in our attempts to stall the spread of COVID-19. Int J Tuberc Lung Dis 2020;24:364-6.  Back to cited text no. 3
    
4.
Smith I. Mycobacterium tuberculosis pathogenesis and molecular determinants of virulence. Clin Microbiol Rev 2003;16:463-96.  Back to cited text no. 4
    
5.
Zaman K. Tuberculosis: A global health problem. J Health Popul Nutr 2010;28:111-3.  Back to cited text no. 5
    
6.
WHO. COVID 19 Strategy update. 2020. Available from: https://www.who.int/publications/m/item/covid-19-strategy-update. [Last accessed on 2020 Jun 11].  Back to cited text no. 6
    
7.
Bong CL, Brasher C, Chikumba E, McDougall R, Mellin-Olsen J, Enright A. The COVID-19 pandemic: Effects on low- and middle-income countries. Anesth Analg 2020;131:86-92.  Back to cited text no. 7
    
8.
Wong CY, Wong KY, Law TS, Shum TT, Li YK, Pang WK. Tuberculosis in a SARS outbreak. J Chin Med Assoc 2004;67:579-82.  Back to cited text no. 8
    
9.
He G, Wu J, Shi J, Dai J, Gamber M, Jiang X, et al. COVID-19 in tuberculosis patients: A report of three cases. J Med Virol 2020;92:1802-6.  Back to cited text no. 9
    
10.
Tadolini M, Codecasa LR, García-García JM, Blanc FX, Borisov S, Alffenaar JW, et al. Active tuberculosis, sequelae and COVID-19 coinfection: First cohort of 49 cases. Eur Respir J 56:2001398. doi: 10.1183/13993003.01398-2020.  Back to cited text no. 10
    
11.
Alfaraj SH, Al-Tawfiq JA, Altuwaijri TA, Memish ZA. Middle East respiratory syndrome coronavirus and pulmonary tuberculosis coinfection: Implications for infection control. Intervirology 2017;60:53-5.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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