Not always COVID - pulmonary BCGosis as an unexpected cause of severe respiratory failure and massive ground glass opacities in the lungs

Introduction: Instillations with balcillus Calmette - Guerin (BCG) are established adjuvant therapy for superficial bladder cancer. Although generally safe and well tolerated, they may cause a range of different, local, and systemic complications. Case description: We present a patient treated with BCG instillations for three years, who was admitted to our hospital due to fever and progressive dyspnea. Blood test revealed elevated CRP and liver function tests. On CT scan massive bilateral ground glass opacities in the middle and lower parts of the lungs, parenchymal infiltrations, bronchial walls thickening, and hilar lymphadenopathy were visible. PCR test for SARS-CoV-2 as well as sputum, blood, and urine cultures were negative. Initial empiric antibiotic therapy was ineffective and respiratory failure progressed with the need of oxygen supplementation of 15l/min. Finally, positive cultures for M. tuberculosis ssp. bovis (BCG) were available from sputum and bronchoalveolar lavage fluid. Antituberculous treatment (rifampin, isoniazid, etambuthol) was implemented together with systemic corticosteroids resulting in the quick improvement of the patient's clinical condition. Due to hepatotoxicity and finally reported resistance of the BCG strain to isoniazid, it was replaced with levofloxacin with a good tolerance. Follow up CT scan showed partial resolution of the infiltrates. The patient was discharged home and continued treatment without further side effects. Conclusion(s): The diagnosis of BCG infection in the lungs must be taken into consideration in every patient treated with BCG instillations and symptoms of unexplained infection.

Genetic diversity of Mycobacterium tuberculosis isolates from northwest of Iran during COVID-19 era

Background: Tuberculosis (TB) is considered one of the most infectious diseases in the world. In this study, we intended to examine the epidemiology of tuberculosis by MIRU-VNTR to define the changes that occur in the transmission of tuberculosis in the region during the COVID-19 era. A total of 120 Mycobacterium tuberculosis isolates were collected from sputum samples of patients referred to East Azerbaijan Center TB from December 2020 to August 2021. Demographic information such as age, sex, place of birth, previous TB history, and relevant medical data was collected. The proportion method was performed for drug susceptibility testing, and the PCR-based MIRU-VNTR method was applied to identify molecular epidemiology relationships. Result(s): The isolates were collected from 78 male (65%) and 39 female (32.5%) Iranian patients and 3 (2.5%) Azerbaijani patients. Ninety-three distinct patterns were identified including 15 clustered patterns and 36 unique patterns. The largest cluster was composed of seven isolates. Furthermore, one cluster with 5 members, four clusters with 3 members, and nine clusters with 2 members. In MIRU-VNTR typing, 75 clusters belonged to the Tabriz region and just 3 to the Republic of Azerbaijan. All isolates were sensitive to rifampin, isoniazid, and ethambutol. Conclusion(s): Results of the current study showed COVID-19 pandemic had a direct effect on the transmission and diagnosis of tuberculosis. Less diagnosis and less clustering can indicate public controls and hygiene, and the use of masks had a direct effect on the transmission and diagnosis of tuberculosis. However, misidentification and less focus on other respiratory infections are expected during the pandemic. Studies on the co-infection of COVID-19 and tuberculosis and the role of mask and sanitization against TB are strongly recommended. Copyright © 2023, The Author(s).

TB DURING THE SEROCONVERSION PHASE

SESSION TITLE: TB and TB-Involved Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Patients who are HIV positive have a high risk of co-infection with tuberculosis (TB). Screening tests for HIV identify antibodies that are present during the seroconversion, or window phase. Here we present a case of reactivation TB during the seroconversion phase of HIV with an initially negative QuantiFERON test. CASE PRESENTATION: A previously healthy 24-year-old female presented with a productive cough. She was found to have leukopenia and apical consolidation on chest CT and was treated for community-acquired pneumonia with mild improvement of symptoms. Her QuantiFERON, COVID-19, and HIV antibody screen were negative;however, her reflex HIV antigen was positive. She re-presented a month later with a worsening cough, drenching night sweats, weight loss, vomiting, and dysphonia. Her chest CT noted a right apical cavitary lesion and bilateral upper lobe micronodules with endobronchial spreading. Her QuantiFERON and HIV antibody were now both positive. She was started on rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy and on raltegravir and emtricitabine/tenofovir. DISCUSSION: Above we describe a case of reactivation TB during the seroconversion phase of HIV with a negative QuantiFERON. Primary TB presents in the middle lobes without signs of structural damage whereas secondary TB typically involves the apices and presents with cavitation. Secondary TB is typically due to reactivation or reinfection in immunosuppressed patients. Although we believe this case is due to reactivation due to radiographic findings, her initial QuantiFERON was negative. However, studies have shown that QuantiFERON may have uncertain results in latent TB infections in patients with underlying HIV (1). Reliable testing for latent TB in HIV-positive individuals is necessary as HIV increases the risk of developing active TB and TB increases the risk of transitioning from HIV to AIDS (2). CONCLUSIONS: TB is one of the top 10 causes of death worldwide and HIV is a common coinfection. To the best of our knowledge, this is the first published report of reactivation TB during the seroconversion phase of HIV with an initially negative QuantiFERON. Overall, more research must be done to identify the risk of infections during the seroconversion phase and physicians must be able to identify radiographic findings concerning for TB in patients with underlying HIV. Reference #1: Elisa Petruccioli, Teresa Chiacchio, Elisa Petruccioli, et al. Effect of HIV-infection on QuantiFERON-plus accuracy in patients with active tuberculosis and latent infection, Journal of Infection, 2020;80(5): 536-546. https://doi.org/10.1016/j.jinf.2020.02.009. Reference #2: Bruchfeld, Judith et al. "Tuberculosis and HIV Coinfection.” Cold Spring Harbor perspectives in medicine vol. 5,7 a017871. 26 Feb. 2015, doi:10.1101/cshperspect.a017871 Reference #3: Johnson JL, Okwera A, Hom DL, et al. Duration of efficacy of treatment of latent tuberculosis infection in HIV-infected adults. AIDS. 2001;15(16):2137-2147. doi:10.1097/00002030-200111090-00009 World Health Organization. Tuberculosis [Internet]. 2021 [cited 2022 Mar. 15];Available from: https://www.who.int/news-room/fact-sheets/detail/tuberculosis DISCLOSURES: No relevant relationships by Loor Alshawa No relevant relationships by Angela Binkowski No relevant relationships by Sara Qutubuddin

MISSED TB DIAGNOSIS DURING THE COVID-19 PANDEMIC: MYTH OR REAL

SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Miliary Tuberculosis (TB) is a rare disorder caused by the hematogenous dissemination of Mycobacterium tuberculosis. Patients infected with Mycobacterium tuberculosis can develop Miliary TB from primary infection or reactivation of a latent infection. Many patients with Miliary TB will present with symptoms of classic tuberculosis and in the pandemic time overlaps with symptoms of Covid-19. Since the Covid-19 pandemic the reported TB diagnosis fell 20% in 2020 and remained 13% lower in 2021 as compared to pre-COVID-19 pandemic. Decrease in cases may be due to pandemic-related mitigation efforts, such as social distancing and wearing masks. CASE PRESENTATION: This patient is a 23-year-old undocumented male who presented to the ED, originally in January of 2021, with complaints of generally not feeling well. He reported feeling feverish and having a poor appetite for the past 2 weeks. At this visit, the patient received testing for COVID-19, Influenza and strep;all of which were negative. He was then discharged home and instructed to follow-up outpatient. In July of 2021, the patient again presented to the ED with complaints of weakness, fevers, cough, and weight loss that have progressively worsened. A chest x-ray and CT chest were performed at this time which were positive for innumerable bilateral upper lobe predominant peri-bronchial vascular nodular airspace opacities and patchy areas of consolidation with central cavitation, highly suspicious for tuberculosis. A QuantiFERON gold test was ordered and the patient underwent bronchoscopy. After 2 weeks of hospitalization, a NAAT test came back positive for Tuberculosis. At this point, the patient was immediately started on rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE). The patient received 2 weeks of RIPE treatment and after being hospitalized for 1 month, he was then discharged home on RIPE therapy with strict instructions to follow-up outpatient. DISCUSSION: Similarities in symptoms of TB and COVID-19 may mean that some people who have TB are being evaluated for COVID-19, but not tested for TB. The case was very unusual in that the infection of TB went undiagnosed during his initial emergency department (ED) during the Pandemic surges. It had not been discovered until presenting to the ED 5 months later with worsening symptoms. In presenting this case, we hope to further education on Miliary TB and prevent future missed diagnoses given the extremely infectious nature of the disease. CONCLUSIONS: The 2020 and 2021 declines may be related to factors associated with the COVID-19 pandemic like similarities in symptoms between COVID-19 and TB disease may have led to missed TB diagnoses;widespread disruptions to healthcare during the COVID-19 pandemic may have delayed TB diagnoses;and Efforts to prevent COVID-19, such as wearing masks and staying six feet away from others, may also reduce the spread of TB. Reference #1: Masahiro Narita, Grace Hatt, Katelynne Gardner Toren, Kim Vuong, Monica Pecha, John A Jereb, Neela D Goswami, Delayed Tuberculosis Diagnoses During the Coronavirus Disease 2019 (COVID-19) Pandemic in 2020—King County, Washington, Clinical Infectious Diseases, Volume 73, Issue Supplement_1, 15 July 2021, Pages S74–S76, https://doi.org/10.1093/cid/ciab387 Reference #2: Cleverley J, Piper J, Jones MM. The role of chest radiography in confirming COVID-19 pneumonia. BMJ 2020;370 : m2426. Reference #3: https://www.cdc.gov/media/releases/2022/s0324-tuberculosis-covid-19.html DISCLOSURES: No relevant relationships by Nawal Aamir No relevant relationships by Gabrielle Gerbino

REACTIVATION MILIARY TB IN THE SETTING OF POSTINFECTIOUS COVID-19 LUNGS

SESSION TITLE: Pathologies of the Post-COVID-19 World SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Tuberculosis, caused from infection by M. tuberculosis, affects 2.7 per 100,000 people in the United States. 1 Miliary, or disseminated, TB is a progressive disease characterized by lymphohematogenous dissemination of TB infection that occurs in only 1-2% of TB cases. Little research has gone into pulmonary complications post recovery from COVID-19 infection, especially reactivation of latent TB. Here we present a case of reactivation of latent TB and progression to miliary TB in the setting of post COVID infection. CASE PRESENTATION: A 49-year-old male presented to the ER with fever, shortness of breath, and chest pain. His CXR showed diffuse bilateral, multifocal infiltrates and laboratory testing later came back positive for COVID-19. Two days later, he came back to the ED with acute respiratory failure with 87% oxygen saturation with ambulation. A CT chest done that showed diffuse lung disease consistent with COVID-19 infection, and a right upper lobe lesion likely a granuloma (image 1). He was treated for COVID pneumonia for ten days in the hospital with Decadron, Lasix, and tocilizumab. He required high flow nasal canula during the hospitalization and was discharged when his respiratory status had improved. One year later, he returns with few days of hemoptysis, fever, and chills. He had a progressive cough and 19 pound weight loss overt the last month. Clinically, he appeared mildly diaphoretic without acute distress. He had a room-air oxygen saturation of 95% without labored respiration and did not have increased oxygen demand. CT of the showed diffuse pulmonary parenchymal abnormalities and uniform nodular consolidative changes in the upper lobes bilaterally with areas of cavitation and multiple areas of lung parenchymal changes consistent with miliary TB (image 2). Sputum culture was positive for acid-fast bacilli, and he was started on RIPE therapy with rifampin, isoniazid, pyrazinamide, and ethambutol. He was symptomatically improved within one week of admission and was hospitalized until three negative sputum cultures were drawn. DISCUSSION: This case report gives us novel understanding of the extent of possible complications post recovery from COVID-19 infection. We have already started to see many patients who have recovered from an initial COVID infection, but progressed to secondary lung disease due to this. In our patient particularly, during his initial presentation he was seen to have upper lobe granulomatous disease with concern for latent TB. It is likely that due to the extent of damage done to his lung parenchyma over time it led to reactivation of his latent TB. As we see more patients recovering from COVID infections, we are likely to see more of similar cases of latent infection reactivation. CONCLUSIONS: Patients with latent TB are likely at a high risk of reactivation post recovering from COVID-19 infection, due to immunosuppression and lung parenchymal damage Reference #1: Trends 2019 ;Data & Statistics ;TB ;CDC. Cdc.gov. https://www.cdc.gov/tb/publications/factsheets/statistics/tbtrends.htm. Published 2021. Accessed September 25, 2021. Reference #2: Rodriquez-Morales AJ et al. Clinical, laboratory, and imaging features of COVID-19: a systemic review and meta-analysis. Travel Med Infect Dis. 34: 101623 Reference #3: Colditz GA, Brewer TF, Berkey CS, et al. Efficacy of BCG vaccine in the prevention of tuberculosis. Meta-analysis of the published literature. JAMA. 1994;271(9):698-702 DISCLOSURES: No relevant relationships by Sharmin Asha No relevant relationships by Heather Bernstein no disclosure on file for zachary brittingham;no disclosure on file for Vedee Ramdass;