A 61-year-old woman with a history of total abdominal hysterectomy and salpingectomy for cervical carcinoma initially visited the surgical clinic with complaints of abdominal bloating and loss of weight for a month, associated with a recent dry cough for one week. She denied shortness of breath, fever, haemoptysis, sore throat, anosmia or dysgeusia. Computed tomography (CT) of the abdomen and pelvis showed no intrabdominal abnormalities, however, ground glass opacities were observed at bilateral lower zones of the lung. Rapid nasopharyngeal and oropharyngeal (NPOP) antigen assay for COVID-19 was positive, and she was admitted to the isolation ward.
On admission, she was apyrexial and normotensive, but was noted to be tachycardic (heart rate of 128 beats per minute), tachypnoeic (respiratory rate of 22 breaths per minute) and had an oxygen saturation of 89% under room air. Arterial blood gas taken under room air revealed type 1 respiratory failure (pH 7.46, PO2 67 mmHg, PCO2 30 mmHg, HCO3 28 mmol/L). Electrocardiogram showed atrial fibrillation with fast ventricular response, but no ischemic or myocarditis changes. Chest radiograph revealed bilateral nodular and airspace opacities (Fig. 1A).
Dexamethasone and lopinavir/ritonavir were administered as per local COVID-19 treatment guidelines at the time. She required invasive mechanical ventilation for three days. Endotracheal aspirates sampled for bacterial culture and respiratory virus PCR panel (QIAstat-Dx, QIAGEN, Maryland, United States) were negative. Post-extubation, she remained oxygen dependent and computed tomography pulmonary angiogram (CTPA) was performed on day 7 of admission. CTPA showed pulmonary embolism in the segmental branch of right descending pulmonary artery, generalized, diffuse peri-bronchovascular ground glass changes bilaterally, interlobular and intralobular septal thickening at bilateral upper lobes, focal consolidation at the lateral basal segment of the left lower lobe, and tree-in-bud nodules bilaterally (Fig. 2A). Sputum smear examination was positive for acid fast bacilli. Molecular testing for M. TB nucleic acids (Cepheid Xpert MTB/RIF, https://www.cepheid.com) revealed no rifampicin resistance. She was commenced on anticoagulant and anti-tuberculous therapy (ATT) consisting of rifampicin, isoniazid, pyrazinamide, and ethambutol, and finally weaned off to room air on day 32 of admission. Follow-on high resolution computed tomography (HRCT) of the thorax at day 40 of admission showed resolution of ground glass changes and absence of septal thickening. However, there were increased diffuse centrilobular lung nodules with traction bronchiectasis at bilateral lower lobes, consistent with endobronchial TB (Fig. 2B). She was discharged well and completed a six-month course of ATT. Chest radiograph taken 3 months post-discharge showed resolving opacities (Fig. 1B).