A Rare Case of Latent Tuberculosis Reactivation in the Setting of COVID-19 Infection

Introduction For decades, tuberculosis (TB) remained the leading cause of mortality due to a single infectious agent globally. In 2020, mortality due to the coronavirus disease 2019 (COVID-19) pandemic exceeded annual rates of death from TB. The impact of active COVID-19 and TB co-infection remain unclear. We present one of the first documented cases of active TB in the setting of COVID-19 infection in the United States. Case Report A 49-year-old man with a past medical history of mediastinal gray zone lymphoma and hypertension presented to the emergency room with a four-day history of diarrhea and hematochezia. The patient immigrated from Vietnam in 1995. Computed tomography imaging revealed thickening of the sigmoid wall, and bilateral pulmonary ground glass opacities consistent with COVID-19 pneumonia, which was confirmed by polymerase chain reaction (PCR). He was also neutropenic from recent chemotherapy. On admission, he began experiencing worsening hypoxia with exertion, and was started on remdesivir and dexamethasone for COVID-19 infection. Serial chest radiographs revealed worsening bibasilar opacities. He continued to have higher oxygen requirements and maxed out on high-flow nasal cannula and non-rebreather with 88-90% oxygen saturation, requiring transfer to the intensive care unit. A complete infectious workup was performed at this point. Cytomegalovirus PCR was positive at 1486IU and was started on ganciclovir. A bronchoscopy was performed but all testing was negative, including that for acid-fast bacilli (AFB) smear. The patient continued to become increasingly hypoxic, acidotic, and septic, and eventually underwent tracheostomy. Twenty days post-bronchoscopy, cultures from the bronchoalveolar fluid came back positive for Mycobacterium tuberculosis (MTB). A new sputum sample was sent and was found to be smear positive (2+ AFB) and MTB PCR positive. The patient was initiated on rifampin, isoniazid, pyrazinamide, and ethambutol therapy. Unfortunately, the patient continued to decompensate and was unable to be weaned off the ventilator. Comfort care was initiated by the family and the patient passed away on hospital day 68. Discussion The patient had several risk factors for latent TB reactivation, including malignancy, long-term corticosteroid use, and COVID-19 infection. Early research has shown that risk of death and recovery time with COVID-19 may be higher in patients with previous or active TB compared to those without. In patients with severe COVID-19 pneumonia and multiple risk factors for immunosuppression, latent TB reactivation should be considered in addition to secondary superinfection.