# COVID-19 and Pulmonary Tuberculosis Coinfection in a Moroccan Patient with Pulmonary Embolism: A Case Report and Literature Review

Authors: Imane Zouaki; Zakaria Chahbi; Mohamed Raiteb; Mohamed Zyani
Journal: Case Reports in Infectious Diseases
 (2022)

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## Abstract

Emerging cases of coinfection of coronavirus disease 2019 (COVID-19) and tuberculosis (TB), although rare, have attracted the attention of health systems around the world and have arisen many concerns about the diagnosis, treatment, and prognosis of this coinfection especially in high TB burden countries. Here, we report a rare case and, to the best of our knowledge, the first reported case in Morocco of simultaneous diagnosis of an active pulmonary TB infection and a COVID-19 pneumonia. We present a case of a sixty-seven-year-old male patient who was admitted to our COVID-19 emergency department with a diagnosis of COVID-19 pneumonia, confirmed by nasopharyngeal swab’s polymerase chain reaction (PCR) for detection of SARS-CoV-2. The atypical radiological findings suggested a TB coinfection which was later confirmed by sputum cultures and Xpert MTB/Rif assay. The patient also presented some complications including thrombosis of the left leg, pulmonary embolism and inaugural ketosis. Treatment was administered as per local protocols: broad spectrum antibiotics, corticosteroids, fixed dose-combination of antituberculosis treatment along with hydration and insulin therapy for ketosis treatment and anticoagulation. The patient was discharged after twenty-three days of hospitalization. Due to the currently limited data, further studies are necessary to establish any possible correlation between COVID-19 infection and the progression of a latent and/or the severity of an active TB infection.


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## Body

## 1. Introduction

The coronavirus disease 2019 (COVID-19) caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is still spreading across the world since its start on December 2019 in Wuhan city, China, and then declared a pandemic by the WHO on March 2020 [1]. The clinical features are dominated by respiratory and flu-like symptoms such as fever, cough, and fatigue. Meanwhile, tuberculosis is still a global burden affecting millions of people every year with the highest mortality rate of any infectious disease [2]. The concurrence of these two pandemics has arisen many concerns in terms of clinical management, differential diagnosis, treatment, and prognosis, especially in high TB burden countries [3]. There is a scarcity in the current literature concerning cases of coinfection of COVID-19 and TB. Here, we report a rare case of simultaneous diagnosis of an active pulmonary TB infection and COVID-19 pneumonia with thrombotic complications.


## 2. Case Presentation

On December 30th, 2020, a sixty-seven-year-old Caucasian male, with no medical or surgical history, presented to our emergency COVID-19 department with persistent dyspnea at rest, along with chest pain, and a persistent cough initially dry becoming productive fifteen days before admission, showing no improvement on clavulanic acid-amoxicillin taken by the patient on self-medication, in a context of fever and night sweats, and deterioration of general status including a weight loss of 10 kg, fatigue, and anorexia. However, the patient had not shown any signs of otorhinopharyngeal viral infection (no anosmia, no taste alteration, no sore throat, and no rhinitis) and had not reported any known close contact with a COVID-19 except that his son had been treated for pulmonary TB infection a year earlier.Upon his admission, physical examination revealed a conscient bedridden patient, febrile at 38°C, tachypneic at 30 cpm, saturation levels at 86% on ambient air, tachycardic at 100 bpm, and normotensive with bilateral rhonchi, a swollen painful left leg with positive Homans’ sign and vesicular eruption on his abdomen. On another note, his admission’s capillary blood glucose was as high as 4 g/l and his urine strip revealed 2 positives for ketones and 2 positives for glucose, thus revealing an inaugural diabetic ketosis. His EKG and cardiac enzymes were normal.His laboratory findings showed an elevated white blood cells count (10240/ml) (normal: 7000–10000/ml) with high neutrophilic count, a microcytic hypochromic anemia at 10.7 (normal: 13–18 mg/dl), lymphocytopenia at 710 (normal: 1500–4000/mL), an elevated C-reactive protein at 208 (normal:<5 mg/l), normal procalcitonin level 0.26 (normal <5), elevated lactate dehydrogenase at 371 (normal: 135–225 U/L), elevated ferritin at 764 ng/ml (normal: 30–400 ng/ml), blood sugar at 2.29 g/l, and bicarbonates at 22.75 (normal: 22–30). His renal and liver full workup was normal. HIV and other viral serologies also came back negative. His chest computed tomography (CT) scan showed foci of pulmonary consolidation with diffused ground-glass opacities and multiple bilateral nodules and micronodules all in favor of a CO-RADS 5 with signs of active tuberculosis (Figure1).Figure 1
CT scan images showing foci of pulmonary condensation and cavitations of the right upper lobe with diffused ground-glass opacities and multiple bilateral foci of nodules and micronodules suggesting CO-RADS 5 with signs of active tuberculosis.His nasopharyngeal swab for COVID-19 reverse transcriptase-polymerase chain reaction (RT-PCR) came back positive, thus confirming a COVID-19 infection. Also, his sputum for MTB PCR was positive with no rifampicin resistance detected revealing a concomitant infection withMycobacterium tuberculosis. A venous doppler ultrasound of his left leg revealed a total thrombosis of the superficial femoral, popliteal, and sural veins.The patient was admitted to one of our COVID-19 isolation units and was put under oxygenotherapy via a high flow nasal cannula at 6 liters/min. He was started on broad spectrum antibiotics (2 g of ceftriaxone) for 10 days, corticosteroids (methylprednisolone) 80 mg for 5 days, 40 mg of prednisolone orally, a fixed dose-combination of antituberculosis treatment (isoniazid + rifampicin + pyrazinamide + ethambutol), and anticoagulation with low-molecular weight heparin enoxaparin at 0.6 IU∗2 per day and was prescribed support stockings. Intravenous hydration was started as per ketosis correction protocol with correction of hydroelectrolytic disorders and intravenous and then subcutaneous insulin therapy with the following regimen: basal insulin in the evening with boluses of rapid insulin three times a day, depending on the patient’s capillary blood sugar.The evolution was favorable with apyrexia on the second day of treatment, the oxygenotherapy was discontinued progressively over 10 days, the patient’s COVID-19 PCR came back negative on day 15th of his admission, and his chest CT scan showed endoluminal defects of the segmental arteries of the left pulmonary base, focal cystic dilatation of the upper right lobe with focal parenchymatous consolidation, multiples bilateral micronodules, and lymphadenopathy in Barety’s compartment all in favor of a pulmonary embolism with signs of active tuberculosis (Figure2).Figure 2
CT scan images showing bilateral micronodules and bronchial dilation in the right upper lobe with parenchymatous opacification. Endoluminal defects of the left pulmonary base suggesting a pulmonary embolism with signs of active TB infection.After a stay of 23 days, the patient was discharged with a prescription of anti-TB therapy, antivitamin K (started on day 15th of admission), and oral corticosteroids (prednisone) for 10 days with progressive degression and a basal bolus insulin regimen.


## 3. Discussion

Our patient presented a rare case of simultaneously diagnosed coinfection of COVID-19 and active pulmonary TB. This coinfection was described in both genders and in all age groups including a three-month-old Gambian patient, with a slight predominance in males and migrants [4]. These cases were only reported in some countries like Italy [5–9], Singapore [10, 11], India [12–15], China [16–19], Brazil [20, 21], Turkey [22, 23], Saudi Arabia [24–26], and Mexico [27].In Table1, we describe clinical features and radiological findings as well as treatment options and outcome in our literature review of reported cases of this coinfection. The most common symptoms of COVID-19 include fever, cough, and dyspnea [56]. These symptoms are also common in TB infection [57] which makes TB diagnosis rather difficult and sometimes even delayed as in some cases. Our patient as well as multiple reported cases have presented unusual symptoms including night sweats, anorexia, weight loss, and hemoptysis (Table 1). These clinical features are typical of tuberculosis [57] and thus are important to look for when a patient presents respiratory complaints especially in high TB burden countries like ours.Table 1
Information on the reported cases.
StudyCountryNumber of patientsMedian ageComorbiditiesClinical presentationRadiological findingsSite of TBCOVID treatmentTB treatmentMortalityTadolini et al. [28]Multicenter49498 COPD/asthma, 8 diabetes, 6 HIV, 5 kidney disease, 7 liver disease, 10 alcoholism, 20 smoking, 4 drug abuse32 fever, 27 cough, 17 dyspnea21 bilateral GGO, 23 cavitation, 25 infiltrates36 pulmonary, 1 extrapulmonary, 12 both22 HCQ, 12 antiviral therapy, 7 AZT, 1 otherNM6 deathsGupta et al. [12]India22443 diabetes, 4 hypertension, 2 seizure disorder, 1 hypothyroidism22 fever, 11 cough, 7 dyspnea, 1 weight loss, 1 headache14 bilateral infiltrates typical of COVID, 9 pulmonary fibrosis, 3 cavitations, 6 infiltrates/consolidation, 2 pleural effusion17 pulmonary, 4 extrapulmonary; 1 disseminatedNM21 (RIF, INH, PYR, ETB), 1 MDR therapy6 deathsStochino et al. [5]Italy20401 COPD, 4 diabetes, 1 psoriasis, 1 hypertension, 1 sickle cell disease12 fever, 9 cough, 3 dyspnea, 3 chest pain, 2 headache, 1 conjunctivitis, 3 asymptomatic1 GGO, 3 interstitial syndrome, 8 cavitations, 14 nodules, 1 pleural effusion, 1 calcification, 2 miliary16 pulmonary, 1 extrapulmonary, 2 both, 1 disseminated20 HCQ14 (RIF, INH, PYR, ETB), 2 MDR therapy, 4 tailored therapy1 deathGül et al. [22]Turkey1640.682 smoking, 2 asthma, 2 cardiac disease, 2 diabetes3 fever, 7 cough, 3 dyspnea, 2 headache, 4 anorexia, 1 hemoptysis, 1 skin rash, 4 asymptomatic9 GGO, 6 infiltration, 4 cavitations, 1 nodules, 1 pleural effusion9 pulmonary, 5 extrapulmonary, 1 both10 HCQ, 8 FAV13 (RIF, INH, PYR, ETB), 1 (RIF, INH, PYR, STR), 1 (RIF, INH, STR, ETB)1 deathHe et al. [16]China356.32 smoking3 fever, 3 cough, 1 chest pain, 2 dyspnea3 GGO, 1 cavitation3 pulmonary3 LOP/RIT, Arbidol1 (RIF, INH, PYR, ETB)0Liu et al. [17]China3401 MDR-TB, 1Aspergillus infection3 fever, 2 dyspnea, 2 cough, 1 myalgia, 1 sore throat, 1 chest pain, 2 respiratory distress, 2 hemoptysis3 GGO3 pulmonary1 AZT, 3 Arbidol, 3 MOX, 2 LNZ1 (ETB/PYR/AMK/LEV), 1 CS, 1 CFZ, 1 LNZ0Yao et al. [18]China350.32 smoking, 1 diabetes3 fever, 3 cough, 3 weight loss, 1 night sweat3 GGO, 2 pleural effusion3 pulmonary2 LOP/RIT, 1 UMF HCL, 2 IFN-α2 RIF, INH, PYR, ETB1 deathCao et al. [19]China147AsthmaUnwellness, poor appetiteCavern calcificationPulmonaryLOP/RITRIF, INH, PYR, ETB0Tham et al. [10]Singapore431.75NM4 fever, 4 cough, 1 dyspnea, 1 weight loss1 GGO, 1 cavitation, 2 pleural effusion,3 consolidations4 pulmonaryNM4 RIF, INH, PYR, ETB0Al Lawat et al. [29]Oman2491 smoking, 1 diabetes, 1 hypertension2 fever, 2 cough,1 dyspnea, 1 chest pain, 1 headache, 1 weight loss1 cavitations, 2 nodules2 pulmonary2 CTX, CLR, and OSE, 2 HCQ, 1 LOP/RIT2 RIF, INH, PYR, ETB0Gadelha Farias et al. [20]Brazil2411 HIV, 1 hepatitis B1 fever, 1 cough, 2 respiratory distress, 1 headache, 1 hemoptysis2 GGO, 1 cavitation2 pulmonary2 HCQ, 2 AZT, 2 CTX2 RIF, INH, PYR, ETB0Yousaf et al. [30]Qatar635.51 diabetes mellitus3 fever, 5 cough, 2 myalgia, 2 headache, 5 weight loss6 infiltrations, 6 cavitation, 1 pleural effusion6 pulmonary6 (HCQ, AZT, CTX)6 (RIF, INH, PYR, ETB)NMShabrawishi et al. [24]Saudi Arabia734.81 HIV7 fever, 6 cough, 2 hemoptysis, 4 night sweats, 6 anorexia, 6 weight loss1 GGO, 7 consolidation, 3 cavitations, 2 nodules, 1 pleural effusion, 1 pneumothorax6 pulmonary, 1 both4 (AZT, CTX), 1 HCQ, 1 (RIB, INH, LOP/RIT)7 RIF, INH, PYR, ETB1 deathKhayat et al. [25]Saudi Arabia140NoneFever, cough, body aches, chest pain, anorexiaConsolidationPulmonaryNMRIF, INH, PYR, ETB0Baskara et al. [31]Indonesia142DiabetesDizziness, headache, cough, abdominal pain, night sweatsGGOPulmonaryAZT, CTX, CTZ, HCQ, OSERIF, INH, PYR, ETB0Vilbrun et al. [32]Haiti126MDR-TBFever, cough, dyspnea, weight lossCavitation ConsolidationPulmonaryNMBDQ, LEV, LNZ, CFZ PYR0Luciani et al. [6]Italy132BCG vaccinationFever, myalgiaConsolidation pleural effusionLOP/RIT, HCQ, LNZ, CLR, TZPRIF, INH, PYR, ETB0Musso et al. [7]Italy145Immunosuppression, alcoholismFever, cough, fatigue, weight loss, respiratory failure.GGO, cavitation, hydropneumothorax, atelectasisPulmonaryHCQ, corticosteroidsRIF, INH, ETB, PYR, AMK, MOXDeathLovino et al. [8]Italy145NoneFever, productive cough, hemoptysis, myalgiaGGO, excavated consolidationPulmonaryNMNM0Rivas et al. [33]Panama2412 HIV2 fever, 1 cough, 2 dyspnea, 1 weight loss2 infiltrationsPulmonary2 AZT, 2 HCQ, 1 CTX, 1 LEV, 1 antiviral therapy2 RIF, INH, PYR, ETB0Pozdnyakov et al. [34]Canada164Diabetes, hypertension, and dyslipidemiaDyspnea, respiratory distress syndromeGGO, interstitial syndromePulmonaryCTXRIF, INH, PYR, ETB1 deathFaqihi et al. [26]Saudi Arabia160Diabetes, hypertensionFever, cough, chest pain, respiratory distress,GGOPulmonaryLOP/RIT, RIB, DEXRIF, INH, PYR, ETB0Starshinova et al. [35]Russia159Heart disease, COPD, emphysema, tuberculosisFever, rhinitis, cough, shortness of breathGGO, infiltration, consolidation, pneumothorax, emphysemaPulmonaryCTX, LEV, AZTRIF, INH, PYR, ETB0Orozco et al. [27]Mexico151DiabetesAnosmia, dysgeusia, cough, dyspneaGGO cavitationPulmonaryOxygenotherapyRIF, INH, PYR, ETB0Marwah et al. [13]India134MDR tuberculosis, chronic hepatitis BProductive cough, dyspnea, weight loss, fever, respiratory failureCavitation nodulesPulmonaryCorticosteroids, oxygenotherapyRIF, INH, ETB, PYR, BDQ0PatiL and Gondhali [14]India175Ex-smokerFever, productive cough, dyspnea, anorexia, weight loss, hemoptysis.GGO, cavitation infiltratesPulmonaryRemdesivir, corticosteroids, anticoagulationRIF, INH, ETB, PYR0Yadav and Rawal [15]India143NoneFever productive cough, chest pain, dyspnea, night sweats, respiratory distress.Bilateral consolidationPulmonaryNMRIF, INH, ETB, PYR0Yadav et al. [36]India126NoneFever productive cough, chest pain, dyspnea, hemoptysis, weight loss, anorexia.ConsolidationPulmonaryNMINH, ETB, PYR, kanamycin, MOX, CFZ, ethionamide0Jacob et al. [37]India120Multiple sclerosisFever productive cough, weight lossOpacityPulmonaryCorticosteroids, oxygenotherapy, antibioticsRIF, INH, ETB, PYR0Ata et al. [38]India128GliomaDizziness, headache, vomitingGGO nodulesPulmonary with CNS involvementHCQ, AZTRIF, INH, PYR, ETB, pyridoxine0Goel Sharma et al. [39]India153Diabetes chronic kidney diseaseFever, cough, dyspnea, hemoptysis, respiratory distressGGO, consolidation, fibrosisPulmonaryAmpicillin, AZT, HCQRIF, INH, PYR, ETB0Singh et al. [40]India176HypertensionFever, respiratory distress, cough, anorexia, weight lossGGO Consolidation, pleural effusionPulmonaryAZT, HCQ, corticosteroidsRIF, INH, PYR, ETB0Sahara and Yokota [41]Japan159NoneFever, productive cough, hemoptysis, anorexia, taste and smell disordersGGO, tree-in-bud patternPulmonaryNMRIF, INH, ETB, PYR0Ortiz-Martínez et al. [42]Colombia134HIV drug use, anxiety disorderFever, dyspnea, headache, cachexia, respiratory distressGGO, miliary, pleural effusionPulmonarySAM, DOX, corticosteroids, oxygenotherapyNMDeathAissaoui et al. [43]French Guiana130NMFever, cough, dyspnea, genera status alteration, weight loss, night sweatsConsolidation, tree-in-bud patternPulmonaryCTX, DOXRIF, INH, ETB, PYR0Bouaré et al. [44]Morocco132HIVFever cough, headache, myalgia.MiliaryPulmonaryHCQ, AZTRIF, INH, ETB, PYR0Cutler et al. [45]USA161ParkinsonFever, cough, hemoptysisPleural effusion, atelectasisPulmonaryHCQ, oxygenotherapyRIF, INH, ETB, PYR0Freij et al. [46]USA15Group A streptococcal pharyngitisFever, headacheClearExtrapulmonaryAMX, HCQ, AZT, corticosteroids, remdesivirNoneDeathButt et al. [47]UK142NoneDyspnea fever, dry cough, fatigueGGO, Pleural effusion, ConsolidationPulmonaryDEX, remdesivirRIF, INH, ETB, PYR0Çinar et al. [23]Turkey155Myelodysplastic disease, kidney disease,Klebsiella pneumoniae infectionFever, cough, dyspneaGGODisseminatedPlasma therapy, FAV, TCZ, meropenemRIF, INH, PYR, ETB0Tolossa et al. [48]Ethiopia155HIVFever productive cough, headache, chest pain, dyspnea, night sweats, weight loss, anorexia, fatigue, hemoptysisPatchy opacitiesPulmonaryCefepime, corticosteroidsRIF, INH, PYR, ETB0Bongomin et al. [49]Uganda137HIV, cryptococcal meningitisFever productive cough, dyspnea, night sweats, weight loss, anosmia, headache, myalgia, episodes of loss of consciousness.GGO, miliaryDisseminatedTZP, corticosteroids, oxygenationNoneDeathWong et al. [11]Singapore147NoneFever, chest pain, productive cough, dyspnea.Opacities cardiomegalyExtrapulmonary (pericardiac)Remdesivir, oxygenotherapyRIF, INH, PYR, ETB0Kozinska and Augustynowicz-Kopeć [50]Poland267.51 smoking, 1 HIV, 1 atrial fibrillation,1 renal insufficiency, 2 treated pulmonary TB, treated urogenital TB1 (cough, fever, dyspnea, sore throat.), 1 no data1 (atelectasis pleural effusion), 1 no data1 pulmonary, 1 disseminatedNo data1 (RIF, INH, PYR, ETB), 1 no data1 deathGerstein et al. [51]USA149Alcoholism cirrhosisFever, dry cough, orthopnea, abdominal painPleural effusion, opacitiesDisseminatedHCQ, plasma infusionRIF, INH, ETB, LEV0Mulale et al. [52]Botswana13 monthsNoneFever, cough, respiratory distress, failure to thriveInfiltrates, opacities, consolidationsDisseminatedAmpicillin, gentamicin, oxygenotherapyRIF, INH, PYR, ETBDeathEssajee et al. [53]South Africa12 y 7 monthsCerebral venous thrombosisLethargy, hemiplegia, respiratory distressMiliaryDisseminatedCorticosteroids, oxygenotherapy, antibioticsRIF, INH, PYR, ethionamide, corticosteroids0Brandi et al. [9]Italy178Bladder cancer, BCG intravesical instillation, diabetes, COPD, abdominal aortic aneurysmFever, cough, dysuria, dyspnea, respiratory distressGGO, miliaryDisseminatedNMRIF, INH, ETBDeathOsejo-Betancourt et al. [54]Colombia171SmokingFever, dry cough, dyspnea, malaise, anosmia, dysgeusiaBilateral alveolar opacities, cavitation, consolidation, nodulesPulmonaryDEX, SAM, oxygenotherapyRIF, INH, PYR, ETB0Pinheiro et al. [21]Brazil168Diabetes, hypertension, chronic liver diseaseFever dyspnea, cough,GGO, opacities, consolidationsPulmonaryNMNMNMOrozco et al. [27]Mexico151DiabetesAnosmia, dysgeusia, nocturnal diaphoresis, cough, respiratory distress.GGO, cavitation, nodulesPulmonaryOxygenotherapyRIF, INH, PYR, ETB0Gbenga et al. [55]Nigeria231.5None2 fever, 2 cough, 2 weight loss, 1 respiratory distress, 1 sore throat.1 reticulonodular infiltrates, 1 opacityPulmonary2 AZT, 2 LOP/RIT, 2 (Vit C, zinc sulfate, prednisone)2 RIF, 2 INH,2 PYR, 2 ETB0In our case, the diagnosis of COVID-19 was confirmed by RT-PCR for SARS-CoV-2 done upon admission, systematically as per national protocols due to the ongoing pandemic. The complementary CT scan showed pulmonary condensation and diffused ground-glass opacities, commonly described in COVID-19 pneumonia [58]. It also revealed bilateral nodules and micronodules which are characteristic of an underlying active TB infection [59]. In the reported cases, other radiological findings suggesting TB infection included infiltrates, consolidation, cavitation, pleural effusion, miliary, and calcification (Table 1). These previous aspects are atypical of COVID-19 and their presence signs a TB coinfection [59] in need of further confirmatory tests.The TB diagnosis in our case was first brought up by the atypical CT scan findings and was later confirmed by GeneXpert MTB/RIF assay and sputum cultures coming back positive for drug susceptible M.tb (Mycobacterium tuberculosis) like most of the reported cases (Table 1). However, drug resistance was reported in some cases (Table 1).In our case, we noted lymphocytopenia, neutrophilia, increased inflammatory markers (CRP and ferritinemia), and LDH which was described in COVID-19 infection and linked to severe disease and higher mortality [60]. On the same note, an elevated D-dimers level was also related to worse prognosis and to high probability of coagulopathy [60]; although not measured in our case, they would have been elevated since our patient had already presented thrombotic complications.Although thrombotic complications are frequent in COVID-19 infection, their exact incidence has not yet been determined. However, it is noted that their rate is higher in critically ill COVID-19 patients admitted to ICU wards in comparison to non-ICU patients [61]. Their pathogenesis could mainly be related to local factors including inflammation and immunothrombosis induced by the viral infection and/or to the usual thrombotic factors such as prolonged bed rest, age, and certain comorbidities [61, 62]. Our patient has presented PE complicating DVT, but studies show that PE could occur independently from DVT which supports the hypothesis of in situ thrombosis mechanism [61, 62]. Fortunately, our patient has made an uneventful recovery, but these complications and specifically PE are considered independent factors of morbidity and mortality in COVID-19 patients [63], highlighting the importance of the close monitoring and the development of prophylactic anticoagulation protocols especially for critically ill patients.There is still no consensus considering the treatment of COVID-19 and tuberculosis coinfection. Our patient received the classic quadruple antituberculosis regimen (isoniazid + rifampicin + pyrazinamide + ethambutol) along with broad spectrum antibiotics for the COVID-19 pneumonia as per the national protocol in Morocco. In the cohort of Tadolini et al., while the antitubercular treatment was the same for drug susceptible M.tb, the reported treatment for COVID-19 was of different combinations of hydroxychloroquine, azithromycin, and lopinavir/ritonavir: 17 patients received a monotherapy, 9 a combination of two drugs, and 2 received 3 or more drugs [28]. Antiretroviral therapy and hydroxychloroquine are empirically used for COVID-19 treatment; however, they were shown to have interaction with antitubercular drugs, especially rifampicin, isoniazid, and second-line treatments [64]. Since these drug interactions have not been fully elucidated, their use in our case was avoided.The use of corticosteroids in COVID-19 is recommended in certain cases to modulate the inflammatory process as in our national COVID-19 protocol. Many cases in literature suggest the possibility of TB reactivation under these immunosuppressive treatments [65], but due to limited data, no conclusion can be drawn about this subject. Recommendations are to administer corticosteroids in a low dose and for a short period of time when it is indicated to avoid inducing immunosuppression and risk opportunistic infections such as TB [66].In the study by Tadolini et al., 9 patients had both diseases diagnosed within the same week including 4 on the same day, and 14 had COVID-19 first [28]. However, the authors failed to show the role of COVID-19 in the progression of TB due to the study limitations. The relationship between COVID-19 and the onset of TB infection is still debatable, but it seems to be bidirectional. Since both infections depend on cellular immunity, temporary immunosuppression caused by SARS-CoV-2 increases susceptibility for new TB infections or reactivation of latent TB infections and vice versa [34].In the same cohort, the mortality rate was as high as 6/49 (12.3%) and was reported in aging patient with 1 or plus comorbidities [28]. The risk factors for this coinfection are comparable to those of TB without COVID-19 including age, COPD, HIV, smoking, diabetes, hypertension, and renal failure. Our patient checked two of these factors, those of age and diabetes, and fortunately presented a moderate pneumonia that did not require intensive care with a favorable evolution.In conclusion, the possible overlap of symptoms of COVID-19 and TB must alert clinicians to think of TB coinfection when confronted with atypical clinical or radiological presentations, especially in migrants and high TB burden countries. Larger studies are needed to fully to explore and establish clear treatment and prevention protocols for this coinfection.Written informed consent was obtained from the patient for using images and other relevant data for publication in this study.


## 4. Conclusion

In the mist of the ongoing pandemic, as all resources are being allocated to the fight against COVID-19, the emerging cases of COVID-19 and TB coinfection is ought to remind us of an evenly important fight, that against TB. Therefore, we strongly recommend testing for both diseases when faced with respiratory symptoms especially in high TB burden countries like ours or at least before atypical clinical or radiological presentations. The available data about these cases is limited still, and further studies are necessary to better comprehend the effects of COVID-19 on TB and vice versa.



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