Case 1
A 46 years old Iranian housewife with a history of chronic coughs since two months ago presented with exacerbation of coughs together with dyspnea. The patient had a history of liver cirrhosis secondary to autoimmune hepatitis and it was being treated with UDCA, azathioprine, spironolactone, and furosemide. The patient has a history of fever, chills, myalgia, bone pain, and exposure to a symptomatic person. She has been a smoker and has received two doses of the COVID-19 vaccine. Vital signs were as follows: temperature of 36.5°C, heart rate of 75/min, blood pressure of 110/80mmHg, a respiratory rate 18 of breaths per minute, and SPO2 of 95%.
In physical examination, the conjunctiva was pale and coarse crackle was auscultated in both lungs. Based on the history and symptoms of the patient, PCR tests for COVID-19 and influenza were taken which were positive simultaneously. Patient treatment started with oseltamivir 75mili per-oral (po) every 12 hours and remdesivir 200mg STAT and 100mg daily through IV-line. In spiral chest CT-Scan, there were multiple patchy ground-glass opacities together with consolidations in both lung fields some of them are cavitated especially in RUL more in favor of TB, and LUL appearance is suggestive of superinfection of COVID-19 or influenza viral pneumonia (Fig. 1). Acid-Fast Bacteria (AFB) test was done for the patient which yielded a 3+ result. Based on tuberculosis diagnosis, fixed-dose combination antituberculosis drug therapy with three ‘tabs started.