LATENT MYCOBACTERIUM TB REACTIVATION IN TWO PATIENTS WITH COVID-19 PNEUMONIA

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Since December 2019, the world has been suffering from the pandemic of the new coronavirus (COVID-19) with a significant mortality rate. It mainly affects the respiratory system with a wide severity range from being asymptomatic to causing severe acute respiratory distress syndrome (ARDS). Few case reports have reported pulmonary tuberculosis co-infection or reactivation in COVID-19 pneumonia patients(1-2). We present two cases of COVID-19 pneumonia who presented, after the resolution of the acute symptoms, with shortness of breath and were found to have pulmonary cavities, suspicious for tuberculosis (TB). CASE PRESENTATION: Case 1: 76-year-old Brazilian male with multiple comorbidities including COPD on home oxygen, who received the monoclonal antibody infusion (Bamlanivimab) a month ago for mild COVID-19 pneumonia, presented with generalized weakness associated with fever and cough. CT chest showed extensive peribronchiolar and centrilobular patchy and nodular opacities with internal cavities (Figure 1 Right). A previous chest x-ray showed left basal lung scarring (Figure 1 left). Case 2: 71-year-old Columbian male with a history of diabetes mellitus and COVID-19 pneumonia treated with dexamethasone and remdesivir for 10 days, presented 3 months later with dyspnea, fever, and productive cough. X-ray and CT chest showed diffuse nodular opacities with dense consolidation in both upper lobes associated with areas of cavitations (Figure 2 Right). A previous chest x-ray did not show any evidence of prior lung pathologies (Figure 2 Left). Bronchial washing PCR was positive for mycobacterium tuberculosis in both cases. DISCUSSION: Cavitary lung lesions are usually caused by mycobacterial, fungal, neoplastic, or autoimmune pathologies. Viral pneumonia, including SARS-CoV and MERS-CoV, is not a common cause of lung cavities even in severe viral infections (3). Although few case reports have reported cavitary lesions as sequelae of COVID-19 pneumonia, common causes should be excluded first. The two most common CT chest findings in COVID-19 patients are ground-glass opacities and bilateral patchy shadowing (4). The presence of lung cavities in such patients should raise the suspicion of TB, especially in high-risk patients. Whether or not the immune system reaction to the COVID-19; including leukopenia, lymphopenia, and an inflammatory cytokine storm can lead to latent TB reactivation is not fully understood yet. However, treatment of COVID-19 with immunosuppressant drugs such as corticosteroids could be a risk factor for TB reactivation. Both of our patients had new lung cavitary lesions with confirmed mycobacterial infection. CONCLUSIONS: Pulmonary cavities in COVID-19 pneumonia patients should raise the suspicion of other pathologies such as tuberculosis, especially in high-risk patients. REFERENCE #1: 1.Tham, S.M., et al., Four Patients with COVID-19 and Tuberculosis, Singapore, April-May 2020.Emerg Infect Dis, 2020. 26(11): p. 2764-2766.10.1056/NEJMoa2002032. REFERENCE #2: 2. Torre, A., et al., Preliminary observations on IGRA testing for TB infection in patients with severe COVID-19 eligible for immunosuppressive therapy. Respir Med, 2020. 175: p. 106204. REFERENCE #3: 3. Zoumot Z, et al. Pulmonary cavitation: an under-recognized late complication of severe COVID-19 lung disease. BMC Pulm Med 21, 24 (2021). https://doi.org/10.1186/s12890-020-01379-14. Guan WJ, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020; 382:1708-1720. DOI: 10.1056/NEJMoa2002032. DISCLOSURES: No relevant relationships by Sherif Elkattawy, source=Web Response No relevant relationships by Muhammad Atif Noori, source=Web Response No relevant relationships by onyeka Nwachukwu, source=Web Response No relevant relationships by John Viechweg, source=Web Response No relevant relationships by Islam Younes, source=Web Response