Rifampicin-Induced Pneumonitis Mimicking Severe COVID-19 Pneumonia Infection

Abstract

BACKGROUND Rifampicin-induced pneumonitis is an infrequent occurrence, with only a few cases reported in the literature. Furthermore, this condition constitutes a diagnostic challenge, particularly in the era of COVID-19 infection. Here, we report a case of rifampicin-induced pneumonitis with clinical, imaging, and histological features of acute respiratory distress syndrome (ARDS), which required severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing to exclude a diagnosis of coronavirus disease 2019 (COVID-19) pneumonia. CASE REPORT A 43-year-old man on anti-TB treatment for TB meningitis developed new-onset fever, fatigue, hypoxemic respiratory failure, and bilateral pulmonary opacities. His clinical, chest X-ray, and CT thorax findings of ARDS were similar to both rifampicin-induced pneumonitis and severe COVID-19 pneumonia. However, reverse transcription polymerase chain reaction (RT-PCR) testing from a nasopharyngeal swab and bronchoalveolar lavage (BAL) via the GeneXpert system was negative for SARS-CoV-2. A detailed workup, including lung biopsy, revealed drug-induced pneumonitis as the cause of his presentation. His pneumonitis improved after discontinuation of rifampicin and recurred following the rifampicin challenge. CONCLUSIONS This case highlights the importance of early, rapid, and accurate testing for SARS-CoV-2 during the COVID-19 pandemic for patients presenting with acute respiratory symptoms, so that accurate diagnosis and early patient management are not delayed for patients with treatable causes of acute and severe lung diseases. Timely identification of rifampicin-induced pneumonitis via a high clinical suspicion, detailed workup, and histopathological analysis is required to avoid permanent damage to the lungs.

Figure 1.

Chest X-ray (CXR) (A. Initial CXR showing bilateral pulmonary opacities, B. Follow-up CXR showing post-treatment resolution of opacities).

Figure 2.

Computed tomography (CT) scan Thorax (Red arrows: Patchy consolidation and air bronchograms consistent with ARDS).

Figure 3.

Photomicrographs of the histology of the lung biopsies (day 5 of admission) in a 43-year-old man with a history of tuberculous meningitis and rifampicin pneumonitis who presented with symptoms that mimicked severe COVID-19 pneumonia with negative test results for SARS-CoV-2 infection. (A) Histology of the lung shows thickening of the alveolar walls (Red arrow) with an increase in mononuclear cells and pink hyaline membranes (Green arrows), consistent with diffuse alveolar damage (DAD) and with acute respiratory distress syndrome (ARDS) and also with rifampicin-induced pneumonitis. Hematoxylin and eosin (H&E) ×200. (B) Histology of the lung shows some residual thickening of the alveolar walls and type II pneumocyte hyperplasia without hyaline membranes. H&E ×400.