PULMONARY CAVITARY TB IN A PATIENT WITH SARS COV 2 PNEUMONIA

Abstract

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: COVID-19 disease caused by SARS COV 2 can lead to severe disease with pneumonia, respiratory failure, and death. Pathologic mechanisms include a cytokine storm with an elevated IL-6 level. Tocilizumab (TCZ), a monoclonal antibody that inhibits IL-6 receptors, has been used as a potential therapeutic intervention. We report a case of rapidly progressive tuberculosis (TB) following TCZ and steroid use. CASE PRESENTATION: A 44-year-old male was placed on invasive mechanical ventilation for worsening hypoxia due to SARS COV 2 pneumonia. Other interventions included high dose steroids, with a cumulative dose of 675 mg over 8 days, and a single dose of 400 mg of TCZ. The Quantiferon TB (QT TB) test performed on day 2 of steroid administration and prior to TCZ use was negative. His respiratory status improved and he was subsequently extubated. One week later, he developed fever with leukocytosis. Respiratory, blood, urine, and fungal cultures, as well as serum galactomannan were negative. Repeat chest X-ray showed persistent multifocal infiltrates. Chest CT scan showed a 6.6 x 9.4 x 9.5 cm soft tissue density consolidation within the right lower lobe with multiple intralesional airspaces. Despite treatment with broad-spectrum antibacterial and antifungal agents, fever and leukocytosis persisted. A second scan revealed increased size of the cavity, from 6 cm to 8 cm, along with multifocal bronchiectasis and bronchiolectasis throughout the right upper lobe, and increased bronchiolectasis and bronchiectasis in right upper, middle and bilateral lower lobes. Three acid-fast bacillus smears of sputum were found to be positive 3+ and the isolate was subsequently identified as Rifampin-susceptible Mycobacterium tuberculosis (MTB). He improved after initiation of a four drug anti-TB treatment with prompt resolution of fever and leukocytosis. Upon further questioning, the patient reported that he had had a positive PPD test in the past after traveling to and from Haiti multiple times and was treated for 3 months in the last 10 years or so. DISCUSSION: This case illustrates the potential for reactivation of latent TB infection with rapid progression to cavitary disease following the use of corticosteroid and TCZ for severe COVID-19. It is possible that prior administration of corticosteroid could have led to a false negative QT TB test. Dual TCZ and corticosteroid likely contributed to impaired MTB host defenses and to the reactivation of incompletely treated latent MTB infection. CONCLUSIONS: Rapidly progressive cavitary TB can follow the concomitant use of TCZ and high dose steroids for COVID-19. Complete TB history, along with TB screening before use could increase the detection of latent TB infection and trigger appropriate interventions to reduce the risk of reactivation of latent TB infection. Reference #1: Russell B, Moss C, Rigg A, Van Hemelrijck M. COVID-19 and treatment with NSAIDs and corticosteroids: should we be limiting their use in the clinical setting?. Ecancermedicalscience 2020;14:1023. Reference #2: Luo P, Liu Y, Qiu L, Liu X, Liu D, Li J. Tocilizumab treatment in COVID-19: A single center experience [published online ahead of print, 2020 Apr 6]. J Med Virol 2020;10.1002. Reference #3: Sotgiu G, Saderi L, Petruccioli E, Aliberti S, Piana A, Petrone L, Goletti D. Quantiferon TB Gold for the diagnosis of tuberculosis: a systematic review and meta-analysis. J Infect 2019;79:444-453. DISCLOSURES: No relevant relationships by Amna Aijaz, source=Web Response No relevant relationships by Svetlana Chernyavsky, source=Web Response Scientific Medical Advisor relationship with Gilead Please note: $1001 - $5000 Added 06/02/2020 by Nadim Salomon, source=Web Response, value=Honoraria Scientific Medical Advisor relationship with VIIV Please note: $1001 - $5000 Added 06/02/2020 by Nadim Salomon, source=Web Response, value=Honoraria Scientific Medical Advisor relationship with Janssen Please note: $1001 - $5000 Added 06/02/2020 by Nadim Salomon, source=Web Response, value=Honoraria Scientific Medical Advisor relationship with Theratechnologies Please note: $1-$1000 Added 06/02/2020 by Nadim Salomon, source=Web Response, value=Honoraria Stock Owner relationship with TXMD Please note: $5001 - $20000 Added 06/02/2020 by Nadim Salomon, source=Web Response, value=Ownership interest No relevant relationships by Arielle Sasson, source=Web Response