Reactivation MycobacteriumTuberculosis Associated Acute Respiratory Distress Syndrome Following COVID-19 Infection

Introduction: Acute respiratory distress syndrome (ARDS) is rare sequela of Mycobacterium tuberculosis (MTb) associated with miliary MTb in setting of immunosuppression. To date, five cases have been reported with MTbassociated ARDS in absence of miliary type of disease. We present a case of reactivation MTb ARDS following recent self-limited COVID-19 infection in otherwise immunocompetent patient. Case presentation: Patient is an 18-year-old male immigrant from Guatemala with past medical history only for confirmed COVID-19 infection one month before initial presentation, not requiring hospital admission. He presented at outside hospital with 5-day history of dyspnea, fever, and cough productive of sputum. Blood cultures, COVID-19 PCR, HIV, and respiratory viral panel were negative;broad-spectrum empiric antibiotics were started. Initial CT chest revealed bilateral consolidation with necrotizing pneumonia and right upper lobe cavitation. He was subsequently intubated for worsening hypoxemic, hypercapnic respiratory failure. Despite paralysis and prone ventilation with lungprotective strategy, he continued to worsen clinically with refractory hypoxemia and hypercapnia;APACHE-II and SOFA scores were 22 and 11, respectively. Patient was transferred to our facility 4 days after initial presentation for consideration of extracorporeal membrane oxygenation (ECMO) support and was immediately placed on venovenous ECMO. Sputum AFB smear was positive, later confirmed to be pan-sensitive MTb by culture;bronchoalveolar lavage (BAL) was positive MTb by PCR and culture. Patient was started on rifampin, isoniazid, pyrazinamide, ethambutol within 48 hours of transfer. He was continued on vasopressor and inotrope support for shock, likely cardiogenic, with left ventricle ejection fraction of 35% and global hypokinesis. Hospital course was complicated by massive hemoptysis requiring bronchial artery embolization. On CT chest angiography, bilateral extensive near-complete airspace opacification with progressive cavitation was seen (see Figure 1). After 35 days on ECMO, patient continued to have no significant clinical improvement with persistent severe shock and multi-organ dysfunction syndrome. Palliative care was consulted. After discussion with family, ECMO support was withdrawn, and patient expired. Discussion: MTb-associated ARDS has a mortality of 60-80%. Early detection and initiation of antitubercular therapy are crucial in successful management. The presence of shock unrelated to sepsis is a poor prognostic factor, as seen in our patient. This case is unique given it is one of few reported cases of reactivated latent MTb after recovery from COVID-19 pneumonia. We postulate that the aggressive nature and rapidity of clinical decompensation of this patient's MTb ARDS may be related to altered immune host mechanisms following COVID-19 infection.