Pulmonary Cavitary Tuberculosis in a Patient with SARS-CoV-2 Pneumonia

Background: COVID-19 disease caused by SARS-CoV-2 can lead to severe disease with pneumonia, respiratory failure, and death. Pathologic mechanisms include systemic inflammation with elevated IL-6 level. Glucocorticosteroids and Tocilizumab (TCZ), a monoclonal antibody that inhibits IL-6 receptors, are used to dampen systemic inflammation. We report a case of progressive cavitary tuberculosis during hospitalization for severe COVID-19 disease. Methods: Case report and data extraction of baseline demographic disease characteristics and longitudinal data extraction of clinical course, treatment and outcomes. Figure 1 can be referred to for a timeline of important clinical events. Results: A 44-year-old male with severe COVID-19 disease was placed on invasive mechanical ventilation. He has a history of diabetes and serum glucose was 222 mg/dL at presentation. Interventions included a single dose of TCZ and high dose steroids, with a cumulative dose equivalent to 717 mg of prednisone. 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. Serial, blood, urine, and fungal cultures, as well as serum galactomannan were negative. Serial chest X-rays showed persistent multifocal infiltrates. On day 29, chest CT scan showed a 6.6 × 9.4 × 9.5 cm soft tissue density consolidation within the right lower lobe with multiple internal airspaces and right hilar adenopathy with calcified subcarinal lymph nodes (Figure 2). A sputum culture grew Klebsiella pneumoniae. Despite treatment with broad-spectrum antibacterial and antifungal agents, fever and leukocytosis persisted. On day 35, a second scan revealed increased size of the infiltrate and cavities together with multifocal bronchiectasis and bronchiolectasis. Diabetes control was suboptimal with 45% (79/174) of serum glucose values >180 (range, 50 to 450 mg/dL). Three acid-fast bacillus smears of sputum were found to be positive 3+ and the isolate was subsequently identified as Rifampinsusceptible Mycobacterium tuberculosis. He promptly 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. Conclusions: This case illustrates that clinical deterioration in severe COVID-19 disease may be associated with the presence of coexisting pulmonary infections, including TB. While we cannot exclude reactivation of latent TB infection in the setting of incomplete TB infection chemoprophylaxis, it is more likely that the patient presented with unrecognized TB. COVID infiltrates may obscure the radiological features of TB. Multiple factors likely contributed to progressive cavitary disease including delated TB diagnosis, suboptimal diabetes control, immunosuppression, and Klebsiella pneumoniae. Timely use of CT scan when clinical response is slow or atypical for isolated COVID-19 disease together with complete microbiologic evaluation could lead to prompt recognition of coexisting pulmonary infections and improved outcomes.