A 63-year-old woman with underlying type 2 diabetes mellitus presented to a district clinic with loss of weight and loss of appetite for the last two months, two weeks of lethargy and poor oral intake, one week of fever and productive cough with whitish sputum, and rapidly worsening shortness of breath for the past two days. She was normotensive but tachycardic (pulse rate 115 beats per minute) and tachypnoeic (respiratory rate 28 breaths per minute) and had an oxygen saturation of 96% under room air. She was hyperglycaemic (13 mmol/L) and pyretic (temperature of 38.5  C). Auscultation of lungs revealed reduced air entry over the right lower zone, and chest radiograph revealed bilateral lower zone airspace opacities with blunting of the right costophrenic angle (Fig. 3A). She was then referred to our centre for further care. On arrival to the emergency department, arterial blood gas revealed type 1 respiratory failure despite on 40% supplementation via Venturi mask (pH 7.5 PO2 69 mmHg PCO2 29 mmHg HCO3 22 mmol/L) and she required bi-level positive airway pressure ventilation.
NPOP sample sent for COVID-19 polymerase chain reaction testing was positive. Dexamethasone, lopinavir/ritonavir and favipiravir were administered as per local COVID-19 guidelines at the time. In view of constitutional symptoms, three successive sputum samples were submitted for smear examination, but were negative for acid fast bacilli. The sputum samples were then cultured in Lowenstein-Jensen media. Her pyrexia subsided and she was weaned off to room air by day 10 of admission. However, on day 12 of admission, she complained of chills and breathlessness, and her saturation dropped to 80% under room air. Repeated chest radiograph showed progression of airspace opacities involving mid zones bilaterally (Fig. 3B). Intravenous meropenem was commenced. She succumbed on day 17 of admission. Posthumously, mycobacterium TB complex was isolated in her sputum sample after seven weeks. First-line drug sensitivity testing confirmed susceptibility to isoniazid, rifampicin, ethambutol, and streptomycin.