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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 11  |  Issue : 4  |  Page : 463-465

A tale of three in symbiosis: TB–COVID-19–Bordetella coinfection


1 Department of Pulmonary Medicine, RVM Institute of Medical Sciences and Research Center, Siddipet, Telangana, India
2 Department of Internal Medicine, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Telangana, India
3 Department of Pulmonary Medicine, Chettinad Hospital and Research Institute, Kelambakkam, Tamil Nadu, India
4 Department of Internal Medicine, RVM Institute of Medical Sciences and Research Center, Siddipet, Telangana, India

Date of Submission15-Aug-2022
Date of Decision15-Sep-2022
Date of Acceptance22-Oct-2022
Date of Web Publication10-Dec-2022

Correspondence Address:
Ravindra Chari Mulkoju
Department of Pulmonary Medicine, RVM Institute of Medical Sciences and Research Center, Laxmakkapally Village, Mulugu, Siddipet - 502 279, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_166_22

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  Abstract 


Coinfections/mixed infections are common in the respiratory tract. Many times existing organisms have similar risk factors and clinical features that make the diagnosis difficult. Coronavirus diagnosed in 2019 (COVID-19) and tuberculosis (TB) are two such diseases. Patients with TB have lower cellular immunity and impaired pulmonary function. In such environment, atypical organisms, can infect and make the outcome unfavorable. A 21-year-old malnourished (body mass index- 15 kg/m2) girl presented with fever and cough for 10 days. Sputum for Cartridge Based Nucleic Acid Amplification Test demonstrated Mycobacterium tuberculosis with no rifampin resistance. Fever persisted (100–101°F) and saturation was dropping even after 10 days of antitubercular treatment. A repeat reverse transcription–polymerase chain reaction was done and was positive. In view of persistent symptoms after 20 days, bronchoscopy was done, and cultures showed Bordetella bronchiseptica. Fever and symptoms resolved completely after initiation of the sensitive drug. Diagnostic delay in coinfections can lead to increased morbidity and mortality.

Keywords: Bordetella bronchiseptica, coinfection, COVID-19, tuberculosis


How to cite this article:
Mulkoju RC, Rajuri V, Leo S, Kolan RR. A tale of three in symbiosis: TB–COVID-19–Bordetella coinfection. Int J Mycobacteriol 2022;11:463-5

How to cite this URL:
Mulkoju RC, Rajuri V, Leo S, Kolan RR. A tale of three in symbiosis: TB–COVID-19–Bordetella coinfection. Int J Mycobacteriol [serial online] 2022 [cited 2023 Feb 5];11:463-5. Available from: https://www.ijmyco.org/text.asp?2022/11/4/463/363162




  Introduction Top


Coinfections or mixed infections are common in the respiratory tract. Many times existing organisms have similar risk factors and clinical features that make the diagnosis difficult. Coronavirus diagnosed in 2019 (COVID-19) and tuberculosis (TB) are two such diseases. Patients with TB have lower cellular immunity and impaired pulmonary function. In such an environment, atypical organisms, such as Bordetella bronchiseptica can infect a patient and pose clinical dilemmas and unfavorable outcomes. We describe a case of mixed TB COVID-19 infection superimposed by B. pneumonia. To our knowledge, this is the first case of TB–COVID–Bordetella-mixed infection reported so far.


  Case Report Top


A 21-year-old malnourished (body mass index: 15) girl without any comorbidities and residing in a hostel presented with fever for 10 days and cough with minimal expectoration for 5 days. Considering the COVID-19 pandemicity, reverse transcription–polymerase chain reaction (RT-PCR) for COVID-19 was done and was negative. Another clinical examination was normal. At the time of presentation, blood pressure was 110/70 mmHg, heart rate: 96/min, Spo2: 94% in room air, and temperature –100.4°F. Sputum for gram stain and culture showed no growth after 48 h. Sputum sample for Cartridge Based Nucleic Acid Amplification Test (CBNAAT) demonstrated Mycobacterium tuberculosis with no rifampin resistance. Blood investigations showed hemoglobin of 8.0 g% (normocytic normochromic) and total leukocyte count (TLC) was 12,300/mm3. Renal and liver function tests were normal. First-line antitubercular treatment (ATT) consisting of isoniazid, rifampin, pyrazinamide, and ethambutol was started. Fever persisted (100–101°F) even after 10 days of ATT and her oxygen saturation dropped to 90% with room air. Due to the worsening of symptoms, RT-PCR test for COVID-19 was done and was positive. Antivirals (remdesivir), steroids (1 mg/kg methylprednisolone), and other supportive measures were administered. There was not much symptom resolution even after 15 days of admission. Patient saturation was further dropped to 85% with room air. Ultrasonography (USG) abdomen showed mild hepatomegaly. TLC was 13,500/mm3, procalcitonin was 1.83 ng/mL, and C-reactive protein was 84.1 mg/dl. Bronchoscopy was done which demonstrated normal bronchial anatomy studded with purulent secretions. On day 3, the causative organism from bronchoalveolar lavage (BAL) was identified as B. bronchiseptica, sensitive to doxycycline. Fever and symptoms resolved completely after initiation of the sensitive drug. There was no relapse in the next 6-month follow-up period.


  Discussion Top


Coinfections or mixed infections are common in the respiratory tract, especially in immunosuppressed patients. In the event of a suboptimal response, suspicion of coinfections must be high. The current scenario suggests that in an individual with TB with nonspecific clinical features and a prolonged clinical course, there may be an infection with COVID-19. TB and COVID-19 both have an affinity for the respiratory tract and share similar clinical features. The two can adversely affect each other's clinical outcomes by disrupting the innate immunity process. Infection with COVID-19 can precede or follow TB, or in some cases, it can even occur simultaneously.[1]

In our case, the patient had a fever, productive cough, and exertional dyspnea. Chest radiology suggested multiple patchy areas of consolidation and cavitation predominantly in bilateral upper lobes highly suggestive of pulmonary Koch [Figure 1]. Due to persisting symptoms despite starting ATT, a RT-PCR test for COVID-19 was carried out, which showed positive results. Hence, she started treatment for COVID-19 infection as well, along with ATT. There are risks associated with TB for respiratory viral infections as well as influenza-related hospitalizations.[2] TB and severe acute respiratory syndrome (SARS) caused by SARS-associated coronavirus (SARS-CoV) coinfections have also been reported in the past. In 2003 SARS pandemic, out of 83 SARS patients, two cases of tubercular reactivation and one new tubercular pulmonary infection were identified.[3] Reinfection could occur due to transient suppression of cellular immunity, which predisposes patients to coinfection. Furthermore, in addition to the viral infection, certain drugs used in the treatment process may also suppress the immunity of the patient, which may lead to coinfections.[4]
Figure 1: Chest CT suggested multiple patchy areas of consolidation and cavitations predominantly in bilateral upper lobes suggestive of pulmonary Koch. CT: Computerized tomography

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In our case, there were persisting symptoms even after 1-week treatment with TB and COVID-19. Repeat RT-PCR (nasopharyngeal swab) for COVID-19 was negative. To rule out other possible causes of fever, a bronchoscopy was performed, which revealed multiple purulent segments on both sides. BAL RT-PCR for COVID-19 was negative and CBNAAT demonstrated M. tuberculosis with no rifampin resistance. The BAL bacterial culture revealed a gram-negative rod-shaped coccobacillus, and it was later determined to be B. bronchiseptica. There were no fungal elements and fungal cultures showed no growth.

Gram-negative coccobacillus, B. bronchiseptica infects animals and humans with immunosuppressed conditions, but immune-competent people can also contract the disease. A literature search revealed a limited number of case reports and series of B. bronchiseptica infections among pediatric and adult populations, especially those with compromised immune systems.[5] We might expect this patient, who has TB and COVID-19 infection, to become infected with B. bronchiseptica after contact with unimmunized dogs either at home or at the hostel due to the underlying immune suppression caused by those infections. B. bronchiseptica exhibits tropism for the respiratory epithelium. The disease spectrum of B. bronchiseptica infection in humans is nonuniform, ranging from asymptomatic colonization to life-threatening pneumonia. In humans, B. bronchiseptica infections primarily affect the respiratory tract (95% of cases), and coughing is the leading symptom. It can also manifest as pertussis-like syndrome or bronchitis, meningitis, and peritonitis.[6],[7],[8],[9] In terms of diagnosis and treatment, there are no clear guidelines regarding B. bronchiseptica infection. The resistant strains of B. bronchiseptica exist; therefore, antibiotics need to be administered based on sensitivity patterns and culture results.[10]

In many cases, the prognosis is fair. Diagnostic delay or noncompliance of medication in mixed infections can lead to increased mortality and also can predispose a patient to the development of drug resistance. In our case, based on radiology appearance and biochemical reports, ATT was started. Underlying immunosuppression by malnourishment predisposed the patient to acquire COVID-19 and B. bronchiseptica coinfection. Timely diagnosis and appropriate administration of antibiotics improved the clinical outcome. To our knowledge, this is the first case of TB–COVID–Bordetella-mixed infection with a favorable outcome reported so far.


  Conclusion Top


Coinfections or mixed infections are common in the respiratory tract, which can be more commonly seen in patients with immunosuppression. A high degree of suspicion is required in cases where the response is suboptimal. Increased vigilance for uncommon infections like B. bronchiseptica, is needed especially in this COVID-19 pandemic, which if left undiagnosed and untreated can result in adverse outcomes.

Limitation of the study

No specific limitations were observed in this case study.

Ethical issues

There is no ethical concern raised in the present case report.

Declaration of patient consent

The authors certify that we have obtained the appropriate patient consent form. In the form, the patient has given her assent and consent for the images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tadolini M, Codecasa LR, García-García JM, Blanc FX, Borisov S, Alffenaar JW, et al. Active tuberculosis, sequelae and COVID-19 co-infection: First cohort of 49 cases. Eur Respir J 2020;56:2001398.  Back to cited text no. 1
    
2.
Abadom TR, Smith AD, Tempia S, Madhi SA, Cohen C, Cohen AL. Risk factors associated with hospitalisation for influenza-associated severe acute respiratory illness in South Africa: A case-population study. Vaccine 2016;34:5649-55.  Back to cited text no. 2
    
3.
Liu W, Fontanet A, Zhang PH, Zhan L, Xin ZT, Tang F, et al. Pulmonary tuberculosis and SARS, China. Emerg Infect Dis 2006;12:707-9.  Back to cited text no. 3
    
4.
Yang H, Lu S. COVID-19 and tuberculosis. J Transl Int Med 2020;8:59-65.  Back to cited text no. 4
    
5.
Woods P, Ordemann K, Stanecki C, Brown J, Uzodi A. Bordetella bronchiseptica pneumonia in an adolescent: Case report and review of the pediatric Literature. Clin Pediatr (Phila) 2020;59:322-8.  Back to cited text no. 5
    
6.
García-de-la-Fuente C, Guzmán L, Cano ME, Agüero J, Sanjuán C, Rodríguez C, et al. Microbiological and clinical aspects of respiratory infections associated with Bordetella bronchiseptica. Diagn Microbiol Infect Dis 2015;82:20-5.  Back to cited text no. 6
    
7.
Wernli D, Emonet S, Schrenzel J, Harbarth S. Evaluation of eight cases of confirmed Bordetella bronchiseptica infection and colonization over a 15-year period. Clin Microbiol Infect 2011;17:201-3.  Back to cited text no. 7
    
8.
Radcliffe C, Lier A, Doilicho N, Parikh S, Kaddouh F. Bordetella bronchiseptica: A rare cause of meningitis. BMC Infect Dis 2020;20:922.  Back to cited text no. 8
    
9.
Dlamini NR, Bhamjee A, Levick P, Uniacke E, Ismail H, Smith A. Spontaneous bacterial peritonitis and pneumonia caused by Bordetella bronchiseptica. J Infect Dev Ctries 2012;6:588-91.  Back to cited text no. 9
    
10.
Papasian CJ, Downs NJ, Talley RL, Romberger DJ, Hodges GR. Bordetella bronchiseptica bronchitis. J Clin Microbiol 1987;25:575-7.  Back to cited text no. 10
    


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