key: cord-0819639-68kzu6ec authors: Starshinova, A.; Guglielmetti, L.; Rzhepishevska, O.; Ekaterincheva, O.; Zinchenko, Yu.; Kudlay, D. title: Diagnostics and management of tuberculosis and COVID-19 in a patient with pneumothorax (clinical case) date: 2021-07-01 journal: J Clin Tuberc Other Mycobact Dis DOI: 10.1016/j.jctube.2021.100259 sha: cbcc504c0d6e3d109325291ea4982c3fab587cdd doc_id: 819639 cord_uid: 68kzu6ec The spread of COVID-19 in countries with high and medium incidence of tuberculosis has led to an increased risk of COVID-19 and tuberculosis co-infection, introducing new diagnostic and therapeutic challenges for the clinician. Hereby we describe a first case where tuberculosis and COVID-19 were diagnosed concomitantly in a Russian patient with pneumothorax. We discuss the challenges associated with the diagnosis and treatment of tuberculosis during the COVID-19 pandemic. The COVID-19/tuberculosis co-infection may further complicate managing of these diseases. The risk of developing severe COVID-19 is high among elderly persons and in the presence of comorbidities such as diabetes, cancer, cardiovascular and chronic bronchopulmonary diseases [2] . Pneumothorax is a common complication in patients with chronic bronchopulmonary diseases and it has been described in patients with COVID-19 [5] . COVID-19 mortality appears to be increased in tuberculosis patients and in particular among those aged 65 years or older [6, 7] . Here, we describe a first case of successful diagnostic of tuberculosis in an older patient from Russia with COPD, emphysema, pneumothorax and COVID-19 pneumonia. Patient M. (59 years old), unemployed, was admitted to an Infectious Diseases Hospital in St-Petersburg, Russia, in June, 2020, with symptoms of rhinitis, dry cough, fever up to 38°C, and shortness of breath when exercising. The patient had a medical history of ischemic heart disease, chronic obstructive pulmonary disease, bullous emphysema, and previous treatment for tuberculosis in the 1980s. Anamnesis of the disease showed that the patient started his treatment since 5 th June at home with amoxicillin and clavulanic acid, a mucolytic (ambroxol), and an antiviral drug (umifenovir) due to suspicion of COVID-19. While on treatment at home, the patient's condition was rapidly deteriorating with dyspnea at rest, leading to hospitalization. At the hospital, COVID-19 was diagnosed based on a positive PCR result on June 10 th . In the hospital ward, a surgical consultation was performed and the left pleural cavity was drained with a Bülau drain, leading to a rapid clinical improvement (reduction of dyspnea). Chest Computed Tomography (CT) scan revealed signs of bilateral viral pneumonia, bullous emphysema, bronchiectasis in the upper lobes of both lungs and left-sided small pneumothorax post-drainage of the left pleural cavity; focal changes with infiltration were found in the lower lobe of the left lung ( Fig. 1 a, b, c) . Paraseptal panlobular bullae were found in both lungs. The foci of ground-glass opacity and consolidations were also detected. The chest X-ray examination on June 30, 2020 showed improvement comparing to June 6, 2020. The treatment was well tolerated during the entire observation period. In addition, the patient showed a clinical and radiological improvement during the treatment. However, sputum smearmicroscopy and culture for M. tuberculosis remained positive (and drug sensitive) through July and August. This case demonstrates the need to exclude alternative, including infectious lung diseases in patients with suspected COVID-19 during the pandemic. A thorough study of the anamnesis and the identification of non-typical changes on the CT scan of the lungs allowed us to suspect a combination of viral pneumonia and tuberculosis in the described patient. The influence of tuberculosis and COVID-19 on the immune status of the patient is a certain complexity, which can lead to both a more severe course of viral infection with an increase in mortality [8] , but also lead to the progression or reactivation of tuberculosis, especially against the background of immunosuppressive therapy, which must be taken into account when selecting therapy [9] . So far, only a few case reports are available in literature on the co-infection of tuberculosis and COVID-19 [10; 11; 12; 13; 14] , and none described a concomitant pneumothorax. The development of pneumothorax in this situation is probably due not only to the presence of bullous emphysema, but also to the development of COVID-19. The literature describes cases of spontaneous pneumothorax in these patients, even without previous mechanical ventilation, which is probably associated with the formation of structural changes in the lung tissue [5, 15; 16] . The number of cases with combined tuberculosis and COVID-19 infections will likely increase during the COVID-19 pandemic, especially in countries with a high burden of tuberculosis infection, as shown by modeling studies [17] . An additional diagnostic challenge in the management of COVID-19 is likely to occur in patients who have both active tuberculosis and HIV infection, which may influence the clinical and radiological presentation, and increase COVID-19 mortality [7, 18] . Taking into account the need for lockdown policies during the COVID-19 pandemic, different research groups have stressed the potential impact on established programs for the diagnosis and treatment of tuberculosis in different countries [1, 6, 7, 17, 19] . In the current epidemic situation, the global healthcare community is facing the spread of COVID-19, which exacerbates major health problems pre-existing the pandemic. Tuberculosis continues to pose a threat to lives and public health systems in many countries, due to its characteristics, which are similar to those of COVID-19: airborne transmission, predominant lung damage, the development of secondary immunosuppression and infection dissemination. COVID-19 may worsen the tuberculosis epidemic through different mechanisms: disrupting the routine process of tuberculosis detection, increasing the risk of reactivation of latent tuberculosis infection, and worsening the clinical presentation of active TB. It is therefore crucial to describe changes in the clinical presentation and morphological characteristics of tuberculosis in patients with a combination of multiple infectious diseases. The authors have no conflicts of interest to disclose. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Predicted impact of the COVID-19 pandemic on global tuberculosis deaths in 2020. medRxiv and bioRxiv Clinical features of patients infected with 2019 novel coronavirus in Wuhan New coronavirus infection: features of the clinical course, the possibility of diagnosis, treatment and prevention of infection in adults and children. Questions of modern pediatrics Saliva Exhibits High Sensitivity and Specificity for the Detection of SARS-COV-2 Pneumothorax in COVID-19 disease-incidence and clinical characteristics COVID-19 and migrants: Preliminary analysis of deaths occurring in 69 patients from two cohorts RSS Risk factors for COVID-19 death in a population cohort study from the Western Cape Province, South Africa. 2020. Clinical Infectious Diseases Active tuberculosis, sequelae and COVID-19 co-infection: first cohort of 49 cases COVID-19 and Tuberculosis COVID-19 in a patient with active tuberculosis: A rare case-report RSS COVID-19 in tuberculosis patients: A report of three cases SARS-CoV-2 and Mycobacterium tuberculosis coinfection: A case of unusual bronchoesophageal fistula Four Patients with COVID-19 and Tuberculosis Three Patients with COVID-19 and Pulmonary Tuberculosis COVID-19 and pneumothorax: a multicentre retrospective case series COVID-19 with cystic features on computed tomography: a case report Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study Doctor's tactics in the detection, diagnosis and prevention of co-infection with HIV and tuberculosis Impact of COVID-19 on Head of the Research Department Linnaeus väg 10 se; +46722029918 Phthisiopulmonologist of the department St. Petersburg City TB hospital №2 (93 Toreza Ave Petersburg Scientific Research Institute of Phthisiopulmonology Ministry of Health of the Russian Federation ulia-zinchenko@yandex.ru Leading Researcher, Laboratory of Personalized Medicine and Molecular Immunology No. 71, NRC Institute of Immunology FMBA of Russia, 24, Kashirskoye highway Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request