Available via license: CC BY 4.0
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Vol. 12(1), pp. 1-3, July-December 2023
DOI: 10.5897/MCS2023.0139
Article Number: A90C23D71312
ISSN 2141-6532
Copyright ©2023
Author(s) retain the copyright of this article
http://www.academicjournals.org/MCS
Medical Case Studies
Case Report
Reactivation of tuberculosis in Covid-19 infected
patient: Case report
Tamar Megrelishvili1, Levan Ratiani2, Tinatin Gaprindashvili2, Nana Saralidze3,
Grigol Nemsadze4, Irakli Chikovani5, Tornike Jashi5, Vera Nemsadze5* and Mariam Silagava5
1Department of infectious Disease, Tbilisi State Medical University, Vazha-Pshavela Ave. 33, 0186, Tbilisi, Georgia.
2Intensive Care Unit, Tbilisi State Medical University, Vazha-Pshavela Ave. 33, 0186,Tbilisi, Georgia.
3Department of Neurology, Tbilisi State Medical University, Vazha-Pshavela Ave. 33, 0186, Tbilisi, Georgia.
4Department of Radiology, Tbilisi State Medical University, Vazha-Pshavela Ave. 33, 0186, Tbilisi, Georgia.
5David Tvildiani Medical University, 2/6 Ljubljana, 0159, Tbilisi, Georgia.
Received 17 August, 2023; Accepted 7 September, 2023
Tuberculous meningitis is a severe manifestation of extrapulmonary tuberculosis, often associated with
substantial morbidity and mortality. This case report discusses a unique presentation of tuberculous
meningitis in a 39-year-old male who was concurrently positive for COVID-19. The patient initially
presented with symptoms of COVID-19, including fatigue, fever, and respiratory distress. However,
subsequent neurological symptoms, including facial asymmetry, ptosis, and dysphagia, led to further
evaluation. Imaging and cerebrospinal fluid analysis confirmed the diagnosis of tuberculous meningitis.
Treatment involved a multidrug regimen and supportive care in an intensive care unit. The patient was
eventually discharged with residual neurological deficits. This case emphasizes the importance of
considering tuberculous meningitis in the context of COVID-19, particularly in regions with a high
burden of tuberculosis. Timely diagnosis, through clinical evaluation and diagnostic tools such as
cerebrospinal fluid analysis and radiographic imaging, is crucial for effective management. The
potential risk of TB reactivation in COVID-19 patients underscores the need for continued vigilance and
prompt intervention to prevent severe disease outcomes.
Key words: Covid-19, tuberculous meningitis, reactivation
INTRODUCTION
Tuberculosis (TB) is a significant global health concern
and remains one of the leading causes of death worldwide
(World Health Organization, 2022a). It is an infectious
disease caused by the Mycobacterium tuberculosis. TB is
spread through the air when an infected person coughs
or sneezes. It primarily affects the lungs, but can also
affect other parts of the body (Centers for Disease
Control and Prevention, 2022).
TB can present in two main forms: latent TB infection and
active TB disease. Latent TB infection occurs when a
person has been infected with the TB bacteria but does
not yet have active disease or symptoms. In this case,
the bacteria are dormant and cannot be spread to others.
However, people with latent TB infection are at risk of
developing active TB disease if their immune system
becomes weakened (Centers for Disease Control and
*Corresponding author. E-mail: Vera.nemsadze@dtmu.edu.ge.
Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution
License 4.0 International License
2 Med. Case Stud.
Prevention, 2022). COVID-19 infection can increase the
risk of TB reactivation due to a combination of factors.
These factors include immune system suppression, as
well as disruptions to TB diagnosis, treatment, and
prevention services (World Health Organization, 2022b).
Tuberculous meningitis (TBM) is one of the most
severe manifestations of extrapulmonary TB. CNS-TB
represented the 13.91% of all cases of meningitis and
4.55% of all cases of TB (Navarro-Flores et al., 2022).
The pathophysiology is primarily driven by three
components, which also explain the clinical symptoms
(Rich and McCordock, 1933; Dastur et al., 1995). Thick
gelatinous exudate, which is especially apparent at the
basal region of the brain, eventually produces a fibrous
mass that encases nearby structures. As a result,
periventricular infarcts and cranial nerve palsies are
developed. Spasm, constriction, thrombosis, and
occlusion of intracerebral arteries are all possible effects
of tuberculous vasculitis and the concomitant
inflammatory vascular changes (Chan et al., 2005). The
intracranial vasculitis is expected to have a major impact
on the remaining neurologic deficits (Poltera, 1977).
Clinical approach and diagnostic tools, including CSF
analysis and radiographic imaging, are equally important
to diagnose TB meningitis (Lewinsohn et al., 2017). The
treatment for tuberculous meningitis is very complex.
Commonly, the combination of Isoniazid, Rifampin,
Pyrazinamide and Ethambutol/Streptomycin/
Fluoroquinolone is given for an extended period of time.
However, sometimes drug resistance is found which
leads to adjustments in treatment (Donald, 2010; World
Health Organization, 2017). This case describes the
development of tuberculous meningitis in a patient with
COVID-19.
CASE PRESENTATION
39-year-old male presented to the emergency department
on June 4, 2022, with fatigue, fever, shortness of breath,
nausea, and vomiting. He tested positive for COVID-19.
A cardiopulmonary examination showed clear lung fields
and normal heart sounds. Neurological assessment
showed signs of ataxia, vertigo, and horizontal
nystagmus; however, a head CT scan has not shown any
pathological features. Two days later, the patient
developed new clinical signs, including facial asymmetry
with loss of the left nasolabial fold, right-sided ptosis,
spontaneous rotatory nystagmus, dysphagia, dysarthria,
and trouble coordinating. Jaw jerk and gag reflexes were
both diminished. Reduced deep tendon reflexes were
present in all extremities, more so on the left. He also
suffered from neck rigidity.
A head MRI revealed hyperintensity in the brainstem
and left cerebellum (Figures 1 and 2). CSF analysis
revealed lymphocytosis, decreased glucose, and
elevated protein. Adenosine deaminase levels and CSF
PCR for tuberculosis were both positive as well.
Following the lumber puncture, treatment with
Dexamethasone, Vancomycin, and Ceftriaxone was
started immediately due to an increased suspicion of
meningitis. After the patient's cerebrospinal fluid results
confirmed TB meningitis, the treatment regimen was
adjusted to Streptomycin, Rifampicin, Isoniazid,
Pyrazinamide and Dexamethasone.
The following day, the patient was diagnosed with
purulent endobronchitis based on an X-ray and
bronchoalveolar lavage. Soon after, he developed a
cytokine storm and was taken to the intensive care unit,
where he was intubated, sedated, and mechanically
ventilated. Due to a protracted need for breathing
support, he underwent tracheostomy placement. The
patient was taken off the ventilator on July 9th, 2022, but
continued to receive oxygen through a tracheostomy.
On August 1, 2022, the patient was discharged with
stable vital signs. Oropharyngeal and cardiopulmonary
examinations revealed no abnormalities. During
neurological examination, the patient was spatially and
temporally oriented and was able to follow simple
commands. Pupils were equally round and light-
responsive. However, he still displayed dysmetria and
Babinski reflex on the left side, along with horizontal
nystagmus, as residual neurological deficit. The patient
was advised to take Rifampicin and Isoniazid for 9
months.
Ethics section
Informed consent was obtained from the patient prior to
data collection, ensuring their comprehensive
understanding of the study's objectives, potential
implications, and the confidentiality of their sensitive
medical information. The patient was provided with
detailed information about the case report, including its
purpose, methodology, and the intended use of medical
records and clinical details. It was explicitly communicated
that participation in the study was entirely voluntary, and
the patient could opt out at any stage without affecting
their medical care or rights. Emphasis was placed on the
de-identification of all data, ensuring the anonymity of the
patient. The patient was reassured that the patient's
personal and medical information would be treated with
the utmost confidentiality and solely utilized for the
purpose of this case report.
DISCUSSION
Based on this case, it is apparent that even a benign
case of COVID-19 may eventually lead to severe
consequences, such as TB reactivation. The timely
identification of early neurological manifestations allowed
for prompt evaluation and diagnosis of TB meningitis,
Figure 1. MRI revealed hyperintensity in the brainstem.
Figure 2. MRI revealed hyperintensity in the left
cerebellum.
which prevented further delays in treatment. So, despite
the severity and complexity of the presented case, the
overall outcome was positive. However, it should be
mentioned that the patient still developed a residual
neurological deficit.
Conclusion
In conclusion, this case highlights that the potential
complications and challenges associated with COVID-19
infection extend beyond the impact of a single infectious
Megrelishvili et al. 3
agent. The combined effects of multiple factors can
significantly affect various organ systems, including the
nervous system. COVID-19 affects several organ
systems, thus any symptom could be attributed to it and
underlying pathology may go unnoticed. The immune
system suppression induced by COVID-19 can increase
the risk of TB reactivation, thereby complicating diagnosis
and treatment. Therefore, it is crucial to consider the
possibility of TB reactivation in COVID-19 patients,
particularly those from regions with high TB prevalence.
Therefore, timely detection and prompt treatment of TB
are essential to prevent severe complications and
improve clinical outcomes in these patients.
CONFLICT OF INTERESTS
The authors have not declared any conflict of interests.
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