Triple infection with disseminated tuberculosis, invasive as
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This is the first reported case of this unusual triple infection, and the article discusses possible disease mechanisms and pharmacological and non-pharmacological challenges in management, specifically with regard to the use of steroids and the determination of ceiling of care in a resource-limited setting.

A 39-year-old man with diabetes mellitus and hypertension presented two years following renal transplantation with evening pyrexia, night sweats and loss of weight. He was diagnosed with disseminated tuberculosis and invasive aspergillosis and commenced on antituberculous and antifungal therapy. Immunosuppressants except for the maintenance dose of steroids were discontinued.

Two weeks later, he acquired severe COVID-19 pneumonia complicated with type 1 respiratory failure and haemodynamic instability. He was treated with non-invasive ventilation and inotropic support with a vasopressor-augmenting dose of steroids. Management challenges were diagnosing the respiratory pathologies with limited investigations, deciding on continuation of steroids in an organ transplant recipient with disseminated infection and deciding the ceiling of care in a low-resource setting given the background of multiple pulmonary insults.

A multidisciplinary team decided to continue high-dose steroids and escalate to a full ceiling of care. He recovered from COVID-19 pneumonia 15 days following diagnosis and was discharged home. The potential adverse effects of steroids on tuberculosis and aspergillosis are to be monitored during follow-up.

Learning points
- This is the first reported case of coinfection with disseminated tuberculosis, invasive aspergillosis and COVID-19 in an immunocompromised patient.

- Decisions regarding the use of steroids in COVID-19 pneumonia in organ transplant recipients with underlying disseminated infections need to be individualised.

- Multidisciplinary team input is needed for deciding the ceiling of care in patients with multiple medical comorbidities with several acute pulmonary insults.