COVID-19 and pulmonary tuberculosis – a diagnostic dilemma
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Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Meanwhile, pulmonary tuberculosis(TB) is one of the most common infective lung diseases in developing nations. The concurrence of pulmonary TB and COVID-19 can lead to poor prognosis, owing to the pre-existing lung damage caused by TB.

A 70-year-old male patient presented with fever, chronic cough with exacerbation of symptoms, and severe breathlessness for 1 week. The patient also had a history of chest pain and few episodes of hemoptysis. On admission, HRCT thorax & RT-PCR for COVID-19 were performed.

HRCT thorax revealed multifocal subpleural ground-glass opacities with superimposed septal thickening (“crazy paving pattern”) in the bilateral lung parenchyma, with dorsal and lower lobe predominance. Chest CT Severity Score was 9 out of 25. The above findings were in favor of atypical pneumonia with CO-RADS (COVID-19 Reporting and Data System) category 5, typical for COVID-19. Further, fibro-cavitatory changes with cylindrical bronchiectasis involving bilateral upper lobes were seen, more in the right upper lobe of the lung. Multiple centrilobular nodules and “tree-in-bud” branching opacities were also noted in the right upper lobe and in superior segments of bilateral lower lobes of the lung. These features were suspicious for concurrent pulmonary tuberculosis, based on the clinical features and imaging. Reverse transcriptase-polymerase chain reaction (RT-PCR) from the nasopharyngeal swab came positive for COVID-19. Furthermore, sputum microscopy revealed acid-fast bacilli (AFB), suggesting pulmonary tuberculosis.

The concurrence of COVID-19 and pulmonary TB can be a diagnostic dilemma. Correct diagnosis and prompt management are imperative to reduce mortality and morbidity. Hence it is pertinent for imaging departments to identify and report these distinct entities when presenting in conjunction.

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