Coinfection of SARS-CoV-2 and MTB: how not to miss the wood
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A young woman aged 20 years, who was on immunosuppressant treatment for multiple sclerosis with dimethyl fumarate 240 mg two times per day for the last 1 year, presented with a history of fever, productive cough of 1 month duration, weight loss, fatigue. There was no history suggestive of contact with patients with COVID-19 positive. She was already diagnosed with COVID-19 by real time-PCR (RT-PCR) assay of the nasopharyngeal swab, done on the same day at another hospital. Physical examination showed peripheral oxygen saturation of 95% on room air, blood pressure of 70/56 mm Hg, respiratory rate of 20 cycles/min. Chest examination revealed crepitations in the right mammary area. Chest X-ray showed right upper and mid-zone nonhomogenous opacity.

In COVID ICU, she was started on intravenous dexamethasone along with inotropes, antibiotics and other supportive care as per the state health agency protocol. However, the history of weight loss, location of the opacity in chest X-ray and background medication history prompted us to consider PTB as a possibility. Matching our expectations, sputum was positive for acid-fast bacilli (AFB). Cartridge-based nucleic acid amplification test (CBNAAT) confirmed the presence of mycobacterium TB.

Resistance to rifampicin was not detected. She was started on standard 4 drug antitubercular regimen containing rifampicin, isoniazid, ethambutol and pyrazinamide as per her body weight. Dimethyl fumarate was continued. During the hospital stay of 10 days, she did not show any features of adverse effects to treatment. Inotropes were tapered and stopped. She required supplemental oxygen via face mask as her Arterial Blood Gas analysis (ABG) in the ICU showed PaO2 of 7 kPa. We were able to taper and stop it over next 12 hours as her saturation gradually improved to 95%. She was not treated with drugs like remdesivir, tocilizumab.

Even after discharge, she was closely monitored for adverse effects (particularly the neurological and ophthalmic-keeping in mind her pre-existing neurological disease) through frequent telephonic enquiries. By the end of intensive phase of 2 months, she had put on 6 kg of weight and all symptoms had subsided. However, her sputum CBNAAT still showed presence of TB bacillus but resistance to rifampicin was not detected. Further testing with Line Probe Assay (LPA) confirmed the absence of resistance to both rifampicin and isoniazid. Now, at the end of 6 months of therapy, her sputum is negative for AFB, she has put on 8 kg of weight in total and all chest reports have subsided.