|Year : 2022 | Volume
| Issue : 1 | Page : 46-49
COVID-19 and tuberculosis − a double trouble
Muniza Bai, G. Vishnukanth, A. Ramyapriya, Manju Rajaram
Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
|Date of Submission||09-Dec-2021|
|Date of Acceptance||24-Jan-2022|
|Date of Web Publication||19-Apr-2022|
Dr. G. Vishnukanth
Associate Professor, Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006
Source of Support: None, Conflict of Interest: None
The coronavirus pandemic has currently overtaken every other healthcare issue across the globe and even stole the limelight of World Tuberculosis (TB) Day. The coronavirus disease disease 2019 (COVID-19) has resulted in diagnostic confusion and many missed diagnoses of presumptive TB owing to the confounding symptoms. There is a diversion of material and manpower from the TB control programs and support systems resulting in an inevitable shift of focus toward COVID-19 and neglect of TB. This has badly impacted the active case finding, diagnosis, management, and follow-up of TB. Late diagnosis also leads to increased severity of the disease. We herein describe two such cases where severe acute respiratory syndrome-related coronavirus 2 and Mycobacterium tuberculosis coexisted and discuss a whole realm of facts and ideas that need to be implemented to curb this complex coexistence. We highlight the importance of bidirectional screening for early diagnosis and prompt management and the importance of teleconsultation or telephonic follow-up in this COVID era.
Keywords: Bidirectional screening, coronavirus, COVID-19, tuberculosis
|How to cite this article:|
Bai M, Vishnukanth G, Ramyapriya A, Rajaram M. COVID-19 and tuberculosis − a double trouble. J Assoc Chest Physicians 2022;10:46-9
| Introduction|| |
The coronavirus pandemic is the defining global health crisis of all time and the greatest challenge we have faced since World War II. Since its emergence in Asia in late 2019, the virus has spread to every continent except Antarctica. It has swiftly overtaken every other health issue across the globe and carved a niche for itself. One such pathogen that was sidelined by the novel coronavirus is the Mycobacterium tuberculosis (MTB), which had claimed the top spot of being a highly infectious pathogen for long, so much so that the severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) even stole the limelight of March 24, the World Tuberculosis (TB) Day. Coinfection with these two major pathogens is indeed dual trouble, a double-edged sword. Experience with treating concomitant coronavirus disease disease 2019 (COVID-19) infection and TB is scarce. We herein describe such a case where SARS-CoV-2 and MTB coexist and discuss a whole realm of facts and ideas that need to be implemented to curb this complex coexistence.
| Case details|| |
A 21-year-old female with no known comorbidities presented with complaints of cough with expectoration for 6 months, breathlessness, and fever for 3 days. History of loss of appetite and loss of weight was present. She denied a history of contact with a confirmed COVID patient. There was no history suggestive of pulmonary TB or anti-TB treatment. Her pulse rate was 120 beats/minute, blood pressure 110/70 mmHg, room air saturation 96%, and respiratory rate 26/minute. Nasopharyngeal swab confirmed COVID-19 by real-time polymerase chain reaction (RT-PCR) assays. She was shifted to the COVID unit. Two days postadmission, she had acute worsening of breathlessness and desaturation. A bedside chest radiograph taken in view of worsening breathlessness revealed a left side hydropneumothorax in addition to bilateral diffuse parenchymal infiltrates with upper lobe predominance [Figure 1]. A left-sided chest tube was placed, following which her breathlessness improved and her oxygen support could be weaned off. Interestingly, a cartridge-based nucleic acid amplification test (CBNAAT) performed on pleural fluid revealed concomitant infection with MTB sensitive to rifampicin. However, her sputum for acid-fast bacilli stain and CBNAAT was negative. She was started on a fixed-dose combination of antitubercular drugs, prophylactic dose of anticoagulant, intravenous dexamethasone, and other supportive measures. She was duly discharged after she turned COVID negative. She was discharged with implantable cardioverter defibrillator in situ in view of persistent air leak. She is currently receiving her antitubercular medication from a nearby government health center. She is doing well and is under telephonic follow-up.
|Figure 1 Patient 1–Chest radiograph showing a left-sided hydropneumothorax in addition to bilateral diffuse parenchymal infiltrates with upper lobe predominance.|
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A 39-year-old female with no known comorbidities presented with complaints of cough with expectoration, left-sided chest pain, and breathlessness for 10 days. She also gave a history of loss of appetite and loss of weight. No significant history was noted. Her pulse rate was 130 beats/minute, blood pressure 100/70 mmHg, room air saturation 94%, and respiratory rate 30/minute. Chest radiograph was suggestive of left upper lobe cavity and left-sided hydropneumothorax, following which a left-sided chest tube was placed [Figure 2]. Her nasopharyngeal swab confirmed COVID-19 by RT-PCR. Her sputum for acid-fast bacilli and CBNAAT came negative; however, MTB was detected in pleural fluid by CBNAAT. She was treated with antitubercular treatment, prophylactic dose of anticoagulant, intravenous dexamethasone, and other supportive measures. She was duly discharged once she turned negative for COVID. The left intercostal drain was left in situ due to a persistent air leak. She is receiving her antitubercular medication from a nearby government health center. She is doing well and is under telephonic follow-up.
|Figure 2 Patient 2–Chest radiograph showing left upper lobe cavity and left-sided hydropneumothorax.|
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| Discussion|| |
Information and experience with TB–COVID coinfection is limited and unclear. Can TB predispose to COVID-19 infection? Patients with TB have lower cellular immunity and impaired pulmonary function. Besides, factors such as previous lung disease − treated or untreated pulmonary tuberculosis (PTB), old age, comorbidities such as diabetes, and HIV increase the likelihood of contracting COVID-19 infection. Hence, it is imperative that TB services remain uninterrupted in this COVID pandemic. In addition, patients with TB should be taught personal protective measures such as infection control measures, cough etiquette, frequent hand hygiene, social distancing, and strict use of face masks. Additional precautions for all people with advanced HIV, poorly controlled HIV, or TB-HIV coinfection are also recommended.
Both SARS-CoV-2 and MTB affect the lungs and they share the upper respiratory tract as the common portal of entry. MTB is transmitted via airborne spread, whereas SARS-CoV-2 gets transmitted by droplet, airborne, and by close contact. The onset of TB is slow and has a long incubation period, whereas SARS-CoV-2 has a rapid onset and the incubation period being 1 to 2 weeks. Although clinical features are similar, cough is usually dry in the case of SARS-CoV-2. On the other hand, TB is characterized by cough with expectoration and hemoptysis can also occur. Breathlessness is observed at a later stage in TB or as a part of pulmonary TB sequelae, whereas it manifests in the early phases of COVID-19 infection. Diarrhea can also be the presenting complaint of COVID infection.
Sputum, lower respiratory tract samples such as endotracheal aspirate, bronchial wash, and gastric aspirate in case of pediatric population are the specimens routinely used to detect MTB. Oropharyngeal and nasopharyngeal swabs are by far the most commonly used specimen to detect SARS-CoV-2. Sputum, endotracheal aspirate, or bronchoalveolar lavage may be used in patients with severe respiratory disease. Sputum microscopy for acid-fast bacilli, CBNAAT, and MTB culture are diagnostic methods for TB, whereas molecular testing for COVID-19 by RT-PCR is the current recommendation. Serologic assays are not recommended for the diagnosis of either TB or COVID-19. Interestingly, the pipeline of COVID-19 diagnostics has flourished impressively within a short span of time. It is important to note that a diagnosis of COVID-19 does not exclude concomitant infection with MTB. Tadolini et al. in a cohort study conducted in a group of 39 patients found that 53% of patients had a history of TB, 28.5% developed COVID-19 initially, 18.3% were diagnosed with TB and COVID simultaneously, whereas 38.8% patients developed COVID-19 when on treatment for TB. Hence, a high index of suspicion is required to look for features that point toward coinfection.
Treatment of TB is no different in patients with COVID than in non-COVID individuals. Experience in joint management of TB and COVID is meager. It is anticipated that TB–COVID coinfection may be associated with poorer treatment outcomes, especially if treatment with anti tuberculosis treatment (ATT) is delayed or withheld. It is unclear whether drug interactions can occur between ATT and antivirals, immunomodulators which may have shown promising results against COVID-19 in certain clinical trials.
The Government of India recommends bidirectional screening for TB and COVID. All newly diagnosed TB cases and those on treatment should be tested for COVID, if found COVID positive − to manage COVID based on MoHFW guidelines and to continue ATT, if found negative − to continue ATT. Similarly, all COVID-positive patients should be asked the four-symptom complex (cough for more than 2 weeks, persistent fever for more than 2 weeks, significant weight loss, and night sweats), history of contact with TB case, and history of TB. If suggestive of TB, the patient should be offered a chest radiograph and upfront CBNAAT/TrueNaT for the diagnosis of TB. Any case of influenza-like illness (ILI) fitting into the four-symptom complex, history of contact with TB case, history of TB, or the persistence of ILI symptoms more than 10 days should be offered a chest radiograph and upfront CBNAAT/TrueNaT for TB. Similarly, in a case of severe acute respiratory illness (SARI) fitting into the above criteria with SARI features persisting for more than 10 days should be offered upfront CBNAAT/TrueNaT for TB.
It also recommends the issue of 1 month of ATT (to a maximum of 2 months of ATT in case of difficult situations) to the newly diagnosed TB cases and those on treatment to prevent treatment interruption. Issue of ATT is also recommended for patients with TB on quarantine or isolation due to active COVID infection. Linkage of TB service centers and COVID isolation setups should be established to provide a continuum of care and prevent treatment interruption. A people-centered approach and community-based care are given priority over hospital-based management unless severe disease warranting admission. This decreases the risk of transmission of both COVID and TB infection. In addition, the TB healthcare workers are advised to counsel, motivate and review the patients periodically over telephonic follow-up.
| Conclusion|| |
Past emergencies caused by influenza, Ebola, SARS, MERS, and Nipah viruses have negatively impacted TB care. Once again, TB care is adversely affected in this coronavirus pandemic. The acute surge of COVID cases has put TB in a backseat and the stress on the working health force may result in the neglect of active case detection of TB. Early diagnosis of both COVID and TB is important as delays in diagnosis and management can result in unfavorable outcomes. Regular follow-up is important as many end up as defaulters due to difficulties in procuring ATT owing to transport issues and lockdown.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]