LAUSR

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: For the last 100 years, the leading infectious cause of death has been tuberculosis (TB) – until 2020, when SARS-CoV2 became a global pandemic. As the incidence of COVID-19 rises, co-infection with TB is expected. CASE PRESENTATION: A 49-year-old Nepali male presented to the emergency room with cough, dyspnea, and lower extremity weakness. He reported anorexia and weight loss over several months. On presentation, he was afebrile with a heart rate of 118 beats/min, respiratory rate of 20 breaths/min, blood pressure of 156/115 mmHg, and oxygen saturation of 89%. Initial examination demonstrated an ill-appearing male with epidermoid cysts of the neck and cervical lymphadenopathy. Auscultation revealed diminished breath sounds bilaterally with intercostal retractions with breathing. Laboratory results included elevated transaminase, CRP, ferritin, and LDH levels. CT imaging showed large bilateral effusions, bilateral lung atelectasis and pleural thickening with no peripheral ground-glass pattern. The patient was screened for COVID-19 and subsequently tested for TB following the findings on imaging. SARS-CoV2 PCR and QuantiFERON gold test were positive on admission. The patient underwent serial diagnostic and therapeutic thoracentesis for his effusions, and the bilateral fluid AFB cultures were positive.Pleural thickening on the CT scan suggested a chronic disease process, without typical COVID-19 findings. Remdesivir, convalescent plasma and steroids were held following TB diagnosis as his presentation supported a more chronic disease trajectory rather than an acute progression of illness. The patient was initially placed on a high-flow nasal cannula and eventually weaned to room air throughout the hospital course with RIPE treatment. After 65 days, he was discharged to a rehab facility. DISCUSSION: The patient's hypoxemia was likely a result of chronic TB given imaging did not reveal typical findings of COVID-19. The presentation of bilateral pleural effusions caused by TB is a rare phenomenon as most cases demonstrate unilateral effusions. Pleural effusions in COVID-19 infection are usually found as a complication of prolonged illness or bacterial superinfections. Blunting the inflammatory response in COVID-19 with steroids can endanger a patient with active TB because it interferes with cellular immunity essential to containing mycobacteria. Although recent evidence suggests that COVID-19 infection severity is higher in the setting of TB co-infection, our patient demonstrated a mild COVID-19 infectious course. Despite his prolonged hospital course, he did not require intubation and his hypoxemia steadily improved. CONCLUSIONS: Our case demonstrates a previously undescribed case of COVID-19 superimposed on TB complicated by bilateral pulmonary effusions. When indicated, it is crucial to screen for both infections due to overlapping symptomatology and the prevalence of these diseases. REFERENCE #1: Mousquer GT, Peres A, Fiegenbaum M. Pathology of TB/COVID-19 Co-Infection: The phantom menace. Tuberculosis (Edinb) 2021;126:102020. REFERENCE #2: Bandyopadhyay A, Palepu S, Bandyopadhyay K, Handu S. COVID-19 and tuberculosis co-infection: a neglected paradigm. Monaldi Arch Chest Dis 2020;90(3). REFERENCE #3: Vorster MJ, Allwood BW, Diacon AH, Koegelenberg CFN. Tuberculous pleural effusions: advances and controversies. J Thorac Dis 2015;7(6):981–991. DISCLOSURES: No relevant relationships by Saad Ahmad, source=Web Response No relevant relationships by Klaus Meinhof, source=Web Response No relevant relationships by Reiichiro Obata, source=Web Response