Latent extrapulmonary tuberculosis infection in a recovered COVID-19 patient: A case report

Objective: COVID-19 infection can inhibit immunologic function and increase susceptibility to reactivation of latent tuberculosis (TB), which may present diagnostic challenges. We present a case of latent extrapulmonary TB activation in a patient with recent COVID-19 infection, which required an extensive evaluation prior to ultimate diagnosis. Background: As per our knowledge, this is the first reported case of latent extrapulmonary TB reactivation after a recent COVID-19 infection. Design/Methods: N/A Results: 55-year-old Southeast Asian male without prior constitutional symptoms presented three weeks after recovery from COVID-19 with acute progressive encephalopathy. MRI brain demonstrated extensive leptomeningeal post-contrast enhancement of the basilar cisterns and scattered multi-territorial ischemic infarctions, raising suspicion for a multitude of infectious and/or neoplastic processes. He underwent several diagnostic procedures including four lumbar punctures, with cerebrospinal fluid demonstrating pleocytosis (both lymphocytic and neutrophilic predominance), elevated protein, and low glucose. All cerebrospinal fluid studies yielded negative results for meningitis/encephalitis PCR, cytology, flow cytometry, AFB stain, CSF SARS-CoV-2 PCR, and CSF MTB PCR. Serum TB IGRA was also negative. Neoplastic work-up with CT chest/abdomen/pelvis demonstrated lytic bone lesions in the manubrium and inferior pubic ramus with extensive lymphadenopathy. This prompted MRI of the whole spine which demonstrated leptomeningeal enhancement of the spine and lytic osseous lesions at C3, T9, T11. The patient underwent biopsy of an external iliac lymph node which was preliminarily negative. Given concern for Mycobacterium tuberculosis (MTB) despite conclusive evidence, he was empirically started on RIPE therapy and corticosteroids. He then underwent manubrial bone biopsy, also yielding negative AFB cultures and pathology. Finally, MTB PCR bone sample tested positive and, three months later, lymph node biopsy culture resulted positive for MTB. Conclusions: Given the fastidious nature of MTB and the challenges associated with its diagnosis, clinicians must remain vigilant about the prospect of co-infection or re-activation of TB in patients with COVID-19.