SARS-CoV-2 coinfection in children with severe airway obstruction due to pulmonary tuberculosis

Abstract

Introduction: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic had a significant impact on tuberculosis (TB) control globally, with the number of new TB diagnoses decreasing. Coinfection with some viruses, especially measles, could aggravate TB in children. This is presumably a result of depressed cellular immunity. Reports on children with TB and SARS-CoV-2 coinfection are limited.

Methods: A retrospective analysis of children up to 13 years old admitted to Tygerberg Hospital, Cape Town, South Africa, from March 2020 to December 2022 with suspected TB-induced airway compression requiring bronchoscopy. Children were included if they presented with severe intrathoracic airway obstruction and/or radiographic evidence of complicated TB. The patients were divided into two groups based on SARS-CoV-2 respiratory polymerase chain reaction results. Demographics, TB exposure, microbiology, SARS-CoV-2 laboratory data, imaging, inflammatory cytokine levels, and bronchoscopy data were collected. Statistical analyses compared SARS-CoV-2 positive and negative groups.

Results: Of the 50 children undergoing bronchoscopy for TB airway obstruction, 7 (14%) were SARS-CoV-2 positive. Cough was more prevalent in the SARS-CoV-2 positive group (p = 0.04). There was no difference in TB culture yield between groups. However, SARS-CoV-2 positive children showed slower radiological improvement at 1 month (p = 0.01), pleural effusions (p < 0.001), and a higher need for endoscopic enucleation (p < 0.001). FDG PET/CT scans indicated an ongoing inflammation in the SARS-CoV-2 positive group.

Conclusions: Coinfection with SARS-CoV-2 in children with TB airway obstruction appears to complicate the disease course, necessitating more medical interventions and demonstrating a longer duration of the TB inflammatory process. Further research is needed to understand the impact of viral infections on TB progression and outcomes in pediatric patients.

Keywords: SARS‐CoV‐2; TB airway obstruction; bronchoscopy; complicated pulmonary tuberculosis.

Figure 1

Chest CT‐scan images of SARS‐CoV‐2 and TB coinfection. (A–E) Post contrast CT of the chest in a 3‐year‐10‐month‐old girl demonstrating tuberculous lymphadenopathy with airway compression and post‐obstructive parenchymal disease. (A–D) Sequential post contrast axial CT slices of the chest on soft tissue window, demonstrate right paratracheal, pre‐carinal, subcarinal and hilar lymphadenopathy (white arrows) with low density centers, causing tracheal compression and narrowing of the bronchus intermedius (black arrow). There is extensive parenchymal disease in the right upper lobe with low density indicating necrosis (curved black arrow) and areas of breakdown with cavitation. Additionally, there is a complex pleural effusion with pneumothorax (curved white arrow). (E) Angled coronal minimum intensity projection slab on lung windows provides an overview of the bowing and displacement of the trachea and narrowing of the bronchus intermedius (black arrow) as well as the complete cut‐off of the right upper lobe bronchus. PET/CT done 5 months after treatment was started: The 3‐year‐10‐month‐old girl with disseminated TB and SARS‐CoV‐2 infection and extensive disease on FDG PET/CT (maximum intensity projection images (MIP) (F)). Intense inhomogenous FDG uptake (SUV_max 6.35) in collapse‐consolidation of the right upper lobe with features of break‐down on the PET/CT fusion images (G) and contrasted CT (H). The right pleural effusion/empyema also showed intense uptake (SUV_max 6.4) (PET/CT fusion images (I) and contrasted CT (J)). (K–N) Non‐contrast CT of the chest in a 4‐year‐10‐month‐old girl demonstrating tuberculous lymphadenopathy with airway compression, lung parenchymal soft tissue masses and incidentally discovered tuberculous spondylitis. (K–M) Sequential non‐contrasted axial CT slices on soft‐tissue window, demonstrate right paratracheal lymphadenopathy (long white arrow) with tracheal compression and in addition, two soft tissue masses involving the parenchyma (black arrows) in the right para‐cardiac and right paravertebral positions. There is also a small right pleural effusion. (N) Focused, magnified view of the most inferior slice of the scan range, demonstrating erosions of the right side of a thoracic vertebral body (curved arrow), with associated paravertebral mass (short white arrow), consistent with tuberculous spondylitis. CT, computed tomography; SARS‐CoV‐2, severe acute respiratory syndrome coronavirus 2; TB, tuberculosis.

Figure 2

(A–F) Post contrast CT of the chest in a 6‐year‐old boy demonstrating tuberculous lymphadenopathy with airway compression and post‐obstructive parenchymal disease. (A–C) Sequential post contrast axial CT slices of the chest on soft tissue window demonstrate pre‐carinal, subcarinal and left hilar lymphadenopathy some of which is enhancing (curved white arrows) and some of which demonstrates low density centers (straight white arrows). There is airway compression including anteroposterior compression of the trachea and long segment narrowing of the LMB (short black arrow), as well as focal narrowing of the left lower lobe bronchus (long black arrow), with parenchymal air‐space changes distal to these in the left lower lobe ‐ the left lower lobe posteriorly lacks bronchograms, fails to enhance and shows focal low density (curved black arrow), indicating necrosis of the lung. (F) Angled coronal minimum intensity projection slab on lung windows provides an overview of the central airway compressions in the LMB (short black arrow) and left lower lobe bronchus (long black arrow). PET/CT done 6 months after treatment was started: The 6‐year‐‐old boy, tested SARS‐COV‐2 positive and was found to also have TB. FDG PET/CT showed intense uptake (SUV_max 10.5) in the large azygo‐oesophageal nodal mass with central necrosis (red arrow, MIP (G) and PET/CT fusion images (H)), and moderate uptake (SUV_max 5.0) in adjacent nodules and tree‐in‐bud changes in the right lower lobe (PET/CT fusion images (I)). Despite improvement on CT (K) there was intense uptake (SUV_max 11.08) in consolidation in the left lower lobe (PET/CT fusion images, (J)). CT, computed tomography; LMB, left main bronchus; MIP, maximum intensity projection; SARS‐CoV‐2, severe acute respiratory syndrome coronavirus 2.