Disclaimer: Early release articles are not considered as final versions. Any changes will be reflected in the online version in the month the article is officially released.
Three Patients with COVID-19 and Pulmonary Tuberculosis, Wuhan, China, January–February 2020
Author affiliations: Wuhan Pulmonary Hospital, Wuhan, China (Z. Yao, J. Nan, H. Huang, Y. Wu, L. Li); School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China (J. Chen, Q. Wang, L. You, H. Yu); Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan (W. Liu); Wuhan University, State Key Laboratory of Virology, Wuhan (Q. Zhang, Y. Liu); Sichuan University, Chengdu, China (L. Liang)
During January–February 2020, coronavirus disease (COVID-19) and tuberculosis were diagnosed for 3 patients in Wuhan, China. All 3 patients had COVID-19 pneumonia. One severely ill patient died after acute respiratory distress syndrome developed. Clinicians and public health officials should be aware of underlying chronic infections such as tuberculosis in COVID-19 patients.
The leading cause of death from a single infectious agent is tuberculosis (TB) (1). Globally, an estimated 1.7 billion persons are infected with Mycobacterium tuberculosis (2), and a country with one of the highest TB burdens in the world is China (2,3). Co-infection with severe acute respiratory syndrome coronavirus (4,5) or Middle East respiratory syndrome coronavirus (6) and M. tuberculosis has been associated with intensive care unit admission. As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerges, we report 2 patients with COVID-19 and laboratory-confirmed TB and 1 with COVID-19 and clinically diagnosed TB in China.
Patient 1 was a 50-year-old man who became ill with fever and productive cough on December 25, 2019. Pulmonary TB had been diagnosed for this patient 20 years ago, for which he received anti-TB treatment for 6 months (Table; Appendix). At hospital admission, chest auscultation detected bilateral rhonchi and wet rales. While hospitalized, the patient experienced continuous fever, respiratory distress, and hypoxia. A computed tomography (CT) scan of his chest showed bilateral emphysema, bullous cysts, and right pleural effusion. The pleural effusion contained elevated concentrations of adenosine deaminase (ADA) and lactate dehydrogenase (LDH), and results of a Rivalta test for pleural effusion and M. tuberculosis DNA tests were positive. Sputum samples were positive for acid-fast bacilli (AFB) and for M. tuberculosis DNA and RNA. On January 28, 2020, a chest CT scan showed progression of bilateral patchy ground-glass opacities (Appendix). The diagnosis was severe pneumonia, laboratory-confirmed active pulmonary TB, anemia, and hypoproteinemia. The patient received anti-TB and corticosteroid treatments and oxygen therapy. The patient’s dyspnea gradually deteriorated; subsequently, acute respiratory distress syndrome developed. On January 29, he died of respiratory and circulatory failure; a throat swab sample taken that day was positive for SARS-CoV-2 RNA.
Patient 2 was a 44-year-old man who became ill with fever, fatigue, headache, and dry cough on January 16. Chest CT scan showed bilateral patchy ground-glass opacities and pleural effusion (Appendix). On February 14, a chest CT scan showed signs of cavitation, which according to the patient’s medical records were new, and a throat swab sample tested positive for SARS-CoV-2 RNA. At admission, the patient had tachycardia. A TB purified protein derivative skin test showed an induration of 7 × 10 mm. Rivalta test was positive for pleural effusion, which contained elevated concentrations of C-reactive protein, LDH, and ADA (35.1 U/L) and was infiltrated with lymphocytes. Sputum and pleural effusion AFB smears were negative. The clinical diagnosis was active pulmonary TB, tuberculous pleuritis, and pleural effusion. While hospitalized, the patient received antiviral drugs and a fixed-dose combination of isoniazid, rifampicin, pyrazinamide and ethambutol. After admission, the patient was found to have type 2 diabetes mellitus, for which acarbose and metformin were prescribed. His signs and symptoms improved after treatment, and he was discharged on March 3 with anti-TB treatment to be continued.
Patient 3 was a 57-year-old man with a 3-year history of diabetes mellitus who on January 16 became ill with cough. In 2001, pulmonary TB had been diagnosed and considered cured. On January 27, 2020, according to the patient’s medical records, a chest CT scan showed signs of TB. On February 3, another CT scan showed bilateral patchy ground-glass opacities (Appendix). On February 5, the patient was transferred to Wuhan Pulmonary Hospital, Wuhan, China, where a test for SARS-CoV-2 was positive. At admission, the patient had tachypnea and a peripheral capillary oxygen saturation of 90%. His sputum was positive for M. tuberculosis DNA. The diagnosis was severe COVID-19 pneumonia and latent pulmonary TB. While hospitalized, the patient received antibiotics, antiviral drugs, corticosteroids, and oxygen support. On February 7, a chest CT scan showed progression of the ground-glass opacities. Immunoglobulin was administered. Additional CT scans showed gradual improvement, and the patient was discharged on March 2.
All 3 patients with SARS-CoV-2 infection and pulmonary TB had COVID-19 pneumonia; illness was moderate for 1 patient and severe for the other 2. The patient in whom acute respiratory distress syndrome developed died of respiratory and circulatory failure.
In consideration of the high disease burden of TB and the rapid spread of COVID-19, the potential effects of a possible interaction between the 2 infections requires attention (7; P. Glaziou, unpub. data, https://www.medrxiv.org/content/10.1101/2020.04.28.20079582v1). As for general COVID-19 patients, the spectrum of disease for COVID-19 patients with TB can vary from moderate to severe respiratory illness and even death. Underlying conditions including chronic obstructive pulmonary disease, diabetes, hypertension, and malignancy have been associated with more severe outcomes in COVID-19 patients (8). However, in our study, the outcome for 1 of the 3 co-infected patients was severe despite his having no other known conditions thought to predispose him to severe COVID-19. Clinicians and public health officials should remain aware of heightened risks caused by chronic infections such as TB in COVID-19 patients.
Dr. Yao is a physician at the Wuhan Pulmonary Hospital, Wuhan, China. His research focuses on respiratory infections and critical care medicine.
We thank Lance Turtle for his insightful comments on our manuscript.
This study was supported by the Ministry of Science and Technology of China, the National Mega Project on Major Infectious Disease Prevention (no. 2017ZX10103005), the National Key Research and Development Program of China (no. 2018YFE0204500), the National Science Fund for Distinguished Young Scholars (no. 81525023), the National Science and Technology Major Project of China (nos. 2018ZX10713001-007, 2018ZX10201001-010, and 2017ZX10103009-005), the Special Fund for COVID-19 Research of Wuhan University, and the Fund for COVID-19 Research of Taikang Insurance Group Co., Ltd, and Beijing Taikang Yicai Foundation. No funders had any role in the study design; the collection, analysis, and interpretation of data; the writing of the article; or the decision to submit it for publication. The researchers confirm their independence from funders and sponsors.
H.Y. has received research funding from Sanofi Pasteur, GlaxoSmithKline, Yichang HEC Changjiang Pharmaceutical Company, and Shanghai Roche Pharmaceutical Company. None of that research funding is related to COVID-19. All other authors report no competing interests.
H.Y., Y. L., and Z.Y. supervised the study. Z.Y., J. N., H.H., Y.W., and L. Li recruited the patients; collected specimens; and collected demographic, clinical, and laboratory data. J.C., Q.W., and L. Liang plotted the figures; J.C., Q.W., W.L., Q.Z., and Y.L. analyzed the data; H.Y., Y.L., and Z.Y. interpreted the results; J.C. and Q.W. wrote the initial drafts of the manuscript. All authors read and approved the final report.
Houben RM, Dodd PJ. The global burden of latent tuberculosis infection: a re-estimation using mathematical modelling. PLoS Med. 2016;13:
Zhao Y, Xu S, Wang L, Chin DP, Wang S, Jiang G, et al. National survey of drug-resistant tuberculosis in China. N Engl J Med. 2012;366:2161–70.
Low JG, Lee CC, Leo YS, Low JG, Lee CC, Leo YS. Severe acute respiratory syndrome and pulmonary tuberculosis. Clin Infect Dis. 2004;38:e123–5.
Liu W, Fontanet A, Zhang PH, Zhan L, Xin ZT, Tang F, et al. Pulmonary tuberculosis and SARS, China. Emerg Infect Dis. 2006;12:707–9.
Alfaraj SH, Al-Tawfiq JA, Altuwaijri TA, Memish ZA. Middle East respiratory syndrome coronavirus and pulmonary tuberculosis coinfection: implications for infection control. Intervirology. 2017;60:53–5.
Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM, et al.; China Medical Treatment Expert Group for COVID-19. Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis. Eur Respir J. 2020;55:
Suggested citation for this article: Yao Z, Chen J, Wang Q, Liu W, Zhang Q, Nan J, et al. Three patients with COVID-19 and pulmonary tuberculosis, Wuhan, China, January–February 2020. Emerg Infect Dis. 2020 Sep [date cited]. https://doi.org/10.3201/eid2611.201536
Original Publication Date: July 15, 2020
Page created: July 15, 2020
Page updated: July 15, 2020
Page reviewed: July 15, 2020
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.