A Case Report of a Pregnant Woman with COVID-19 and Tuberculosis : Infectious Diseases & Immunity

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Short Report & Case Report

A Case Report of a Pregnant Woman with COVID-19 and Tuberculosis

Song, Weiwei1; Li, Jingru2; Abulizi, Nadila3; Peng, Tao1; Fang, Ke1; Xie, Na1; Shu, Zhanjun2,3,∗

Author Information
Infectious Diseases & Immunity: September 2, 2022 - Volume - Issue - 10.1097/ID9.0000000000000064
doi: 10.1097/ID9.0000000000000064
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Abstract

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sustained transmission around the world, in middle of April 2022, more than 500 million people have been infected, resulting in more than 6 million deaths in more than 200 countries,[1] and these numbers continue with a staggering rate increase. Severe acute respiratory syndrome coronavirus 2 is accompanied by many chronic conditions, including noncommunicable and communicable diseases, such as diabetes mellitus, hypertension, and tuberculosis, and also occurs in different population, such as children, the older people, and pregnant women.

Case presentation

The written informed content was obtained from the patient. The case of a 33-year-old woman with 32 weeks of pregnancy was admitted to the hospital with cough and night sweats for 4 months and fever for 5 days, and reverse transcriptase–polymerase chain reaction testing results confirmed SARS-CoV-2 infection. The patient had cough, sputum expectoration, fatigue, and night sweats without obvious inducement in the past 4 months and gradually showed shortness of breath.

A focal calcification in the lungs was revealed on a chest computed tomography (CT) during a physical examination. The patient’s medical history was gravida 2, parity 1, and the last menstrual period was December 22, 2019. There was no history of secondary diseases, such as genetic disease.

Laboratory studies showed a white blood cell count of 5.2 × 109/L (reference range, 4.0 × 109/L to 10.0 × 109/L), red blood cell count of 4.4 × 1012/L (reference range, 3.5 × 1012 to 5.0 × 1012), with 78% neutrophils, platelet count of 346 × 109/L (reference range, 100 × 109 to 300 × 109), lymphocyte count of 1.1 × 109/L (reference range, 0.8 × 109 to 4.0 × 109), alanine aminotransferase count of 257 U/L (reference range, 0 to 35 U/L), C-reactive protein count of 34.0 mg/L (reference range, 4.4 mg/L to 46.8 mg/L), T-spot positive, and acid-fast bacilli that were found in sputum. The SARS-CoV-2 virus nucleic acid and antibody were positive [Table 1].

Table 1 - Relevant laboratory data
Variables 0 d 7 d 15 d 28 d
WBC, 109/L 5.2 8.1 5.5 5.5
RBC, 1012/L 4.4 3.7 3.7 4.0
PLT, 109/L 346 400 409 295
LYMPH, 109/L 1.1 1.6 1.6 1.4
ALT, U/L 257 27 25 30
d-dimer, mg/mL 1.26 1.47 0.65 0.34
CRP, mg/L 34.0 37.4 13.0 14.0
CD4+ T, cells/uL 356 425 623 625
CD8+ T, cells/uL 160 260 415 430
SpO2, % 96 98 98 97
Acid-fast bacilli 4+ 1+ 1+ 1+
COVID-19 IgG, g/L 23 30 50 74
COVID-19 IgM, g/L 6 28 77 105
WBC: White blood cells; RBC: Red blood cells; PLT: Platelet; LYMPH: Lymph; ALT: Alanine transaminase; CRP: C-reactive protein; SpO2: Peripheral capillary oxygen saturation; COVID-19: Coronavirus disease 2019; IgG: Immunoglobin G; IgM: Immunoglobin M.

The CT scan revealed multiple patchy glass shadows in the middle and lower lobe of the right lung, accompanied by pleural adhesions [Figure 1]. In the lower lobe of the right lung, there is a miliary high-density shadow along the bronchus, with branching signs, thick-walled cavities, smooth inner wall, and margin. A high-density miliary-like shadow can be seen along the bronchus in the lower lobe of the left lung. She was diagnosed with COVID-19 and secondary pulmonary tuberculosis. A fetal ultrasound revealed a normally intrauterine fetus with normal anatomy of approximately 32 weeks of gestational age.

F1
Figure 1:
Imaging findings of the chest. A chest computed tomography image in the pulmonary on hospital day 1 (A and B) showed a few ground glass shadows and patchy increased density shadows in both lungs, multiple cavities formation in the right lower lung. On hospital day 15 (C and D) showed that the patchy ground glass shadow of the right lung was obviously absorbed, the body temperature dropped to normal after treatment, and cough and sputum were relieved than before. On hospital day 26 (E and F) showed the tuberculosis foci were basically absorbed and the patchy ground glass shadow was completely absorbed. The fifth month of review (G and H) showed visible fiber stove, nodule stove, and partial small amount of calcification in the upper, middle, and left lungs of the right lung. Thin-walled voids can be seen in the middle of the right lung.

Because SARS-CoV-2 is a newly identified virus, it remains unknown whether the viral shedding during delivery occurs or the vertical transmission exists. Cesarean section was performed to prevent and control possible infection of the newborn with SARS-COV-2. Reverse transcription–quantitative polymerase chain reaction results of the placenta, umbilical cord, cord blood, amniotic fluid, vaginal fluid, breastmilk, neonatal stool sample, and nasopharyngeal samples were all negative.[2,3]

The baby girl was then transferred from the infectious disease department to the neonatology department. The routine examination of the newborn was 2600 g in weight, 47 cm in length, 9 points in Apgar score in 1 minute, and 10 points in Apgar score in 5 minutes.

The newborn was given formula instead of breast milk ever since, and the results of the examination were also normal in isolation ward of the general hospital.

Taking into account the severe manifestations of COVID-19 and tuberculosis in pregnant women, we have developed strict treatment measures for her. She was administered with antituberculous therapy, including moxifloxacin, amikacin sulfate, cycloserine, and rifapentini, starting 1 week after operation [Table 2]. On hospital day 24, SARS-CoV-2 virus nucleic acid and acid-fast bacilli in sputum were negative. The chest CT scan revealed that the ground glass shadow in both lungs was absorbed more than before [Figure 1].

Table 2 - Treatment therapy after cesarean section
Drugs Usage Time
Cefuroxime sodium injection 1.5 g bid 2 d
Bicyclic alcohol 50 mL tid 22 d
Glycyrrhizinate monoamine cysteine 100 mL qd 14 d
Moxifloxacin 0.4 g qd 6 mo
Amikacin sulfate 0.4 g qd 6 mo
Cycloserine 0.25 g bid 6 mo
Rifapentin 0.45 g biw 6 mo
bid: Twice a day; biw: Twice a week; qd: Once a day; tid: Thrice a day; d: Days; mo: Months.

At the fifth month of follow-up, the patient’s clinical symptoms were largely absent and her baby was healthy.

Discussion

During any epidemic of COVID-19, pregnant women constitute an extremely sensitive group because of altered physiology and immune functions. The management of pregnant patients is no different from that of ordinary patients, except for the treatment of the infection itself.[4]

This report highlights a case of a 32-week pregnant woman with COVID-19 and tuberculosis delivering a healthy baby. In addition, after 5-month follow-up, most of the clinical symptoms have largely disappeared and her baby is healthy too.

In this case, the newborn was reported to be in good condition, which may be related to the high attention paid to the prenatal and delivery process and the cesarean section. There is no evidence of vertical transmission between mother and newborn, and SARS-COV-2 has not been isolated from breast milk.[5]

It is recommended that lying-in women with COVID-19 stop breastfeeding until the infection has been resolved or cured to ensure the safety of the baby and that the mother’s lactation should be maintained while temperature and vaginal bleeding should be closely checked. COVID-19 is not an indication for termination of pregnancy. To ensure the safety of pregnant women, personalized treatment should be developed based on gestational age, pregnancy complications, and fetal condition, combined with relevant laboratory examination, chest CT examination, and SARS-COV-2 virus testing.

Whether COVID-19 is having a profound impact on pregnant women and fetuses remains to be explored.

Studies have confirmed that tuberculosis is at risk of transmission to the fetus through blood, placenta, umbilical cord, amniotic fluid or inhalation, and swallowing of the fetus. Neonates (<4 weeks) should be given an Apgar score immediately after birth. If the newborn is in good physical condition and has no abnormal symptoms, Apgar score is more than 8 after delivery, congenital tuberculosis is excluded, and there is no history of active tuberculosis exposure, the newborn should be considered as healthy and should be vaccinated with Bacillus Calmette-Guérin.

Whether to isolate and breastfeed depends on the mother’s condition and medication. The patient’s pulmonary tuberculosis was treated with moxifloxacin, amikacin sulfate, cycloserine, and rifapentin. Moxifloxacin belongs to quinolone antibiotics, and the main antibacterial spectrum is gram bacterium and Mycobacterium tuberculosis; amikacin sulfate belongs to aminoglycoside broad-spectrum antibiotics, which can interfere with protein synthesis and prevent bacterial growth; cycloserine is not easy to produce drug resistance and can inhibit the synthesis of bacterial cell wall mucopeptides, resulting in cell wall defects; rifapentin has longer half-life and good drug resistance. The doctor chose this antituberculosis treatment program mainly because she is currently in the stable stage of tuberculosis, and the drug should be mainly used to control bacterial growth and disease recurrence. Mycobacterium tuberculosis is prone to drug resistance, so this treatment program was selected.

Through this case, it can be found that there is no direct effect between tuberculosis and COVID-19. Although some authors suggest that the risk of death is higher in COVID-19 patients with tuberculosis than in nontuberculosis patients,[6,7] further research is needed to confirm this.

In addition, the combination of cognitive psychotherapy, dietary changes, and mindful activities can not only provide timely and effective management of anxiety symptoms but also improve maternal and fetal outcomes.

Funding

This work was supported by the provincial and ministerial joint project of the State Key Laboratory for the Prevention and Treatment of High Morbidity in Central Asia (SKL-HIDCA-2019-ZY4) and Prevention and Treatment of Major Infectious Diseases such as AIDS and Hepatitis (SQ2018ZX100302).

Conflicts of Interest

None.

Author Contributions

Weiwei Song, Jingru Li and Nadila Abulizi drafted and revised the manuscript and played an important role in interpreting the results. Tao Peng, Ke Fang and Na Xie interpreted the results. Zhanjun Shu designed the work and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors approved the final manuscript.

References

1. Johns Hopkins Coronavirus Resource Center. COVID-19 dashboard by the Center for System Science and Engineering (CSSE) at Johns Hopkins University (JHU). Available from: https://coronavirus.jhu.edu/map.html. Accessed May 11, 2022.
2. Berg JA, Shaver J, Woods NF, et al. Women's sexual/reproductive health and access challenges amid COVID-19 pandemic. Nurs Outlook 2022;70(2):238–246. doi:10.1016/j.outlook.2022.01.003.
3. Duan K, Liu B, Li C, et al. Effectiveness of convalescent plasma therapy in severe COVID-19 patients. Proc Natl Acad Sci U S A 2022;117(17):9490–9496. doi:10.1073/pnas.2004168117.
4. Gujski M, Humeniuk E, Bojar I. Current state of knowledge about SARS-CoV-2 and COVID-19 disease in pregnant women. Med Sci Monit 2020;26:e924725. doi:10.12659/MSM.924725.
5. Bhatt H. Should COVID-19 mother breastfeed her newborn child? A literature review on the safety of breastfeeding for pregnant women with COVID-19. Curr Nutr Rep 2021;10(1):71–75. doi:10.1007/s13668-020-00343-z.
6. Tadolini M, García-García JM, Blanc FX, et al. On tuberculosis and COVID-19 co-infection. Eur Respir J 2020;56(2):2002328. doi:10.1183/13993003.02328-2020.
7. Sy KTL, Haw NJL, Uy J. Previous and active tuberculosis increases risk of death and prolongs recovery in patients with COVID-19. Infect Dis 2020;52(12):902–907. doi:10.1080/23744235.2020.1806353.
Keywords:

COVID-19; Tuberculosis; Pregnant woman

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