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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 264-267

Pulmonary tuberculosis presenting as acute respiratory distress syndrome and pulmonary embolism


Department of Paediatrics, GMERS Medical College and Sola Civil Hospital, Ahmedabad, Guajrat, India

Date of Submission29-Jan-2021
Date of Decision17-Apr-2021
Date of Acceptance23-Jun-2021
Date of Web Publication27-May-2022

Correspondence Address:
Nehal Patel
Department of Paediatrics, GMERS Medical College and Sola Civil Hospital, Ahmedabad - 380 060, Guajrat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_17_21

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  Abstract 


This series describes six pediatric cases who presented as severe acute respiratory illness during the pandemic of COVID-19 with high D-dimer levels. All six patients tested negative for novel coronavirus. They were diagnosed as having tuberculosis (TB) on detailed investigations; high D-dimer levels are one of the most important indicators of the pulmonary embolism. Pulmonary embolism is a rare presentation of TB, and this study emphasizes the need of keeping TB as an important differential diagnosis of those who present as acute respiratory distress syndrome.

Keywords: Acute respiratory distress syndrome, pulmonary embolism, tuberculosis


How to cite this article:
Dhamecha N, Nagadia Q, Gupta A, Patel N, Thanvi R, Pandav G. Pulmonary tuberculosis presenting as acute respiratory distress syndrome and pulmonary embolism. CHRISMED J Health Res 2021;8:264-7

How to cite this URL:
Dhamecha N, Nagadia Q, Gupta A, Patel N, Thanvi R, Pandav G. Pulmonary tuberculosis presenting as acute respiratory distress syndrome and pulmonary embolism. CHRISMED J Health Res [serial online] 2021 [cited 2022 Jul 7];8:264-7. Available from: https://www.cjhr.org/text.asp?2021/8/4/264/346099




  Introduction Top


Tuberculosis (TB) is a very prevalent disease in developing countries. Pulmonary TB (PTB) usually presents with complaints of cough and fever along with weight loss. PTB presenting as severe acute respiratory illness due to pulmonary embolism is not usual entity. On the other hand, ongoing recent illness novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS Co-V2]/COVID-19) is known for its presentation as SARS and high d-dimer levels.

Here, we are presenting a case series of six patients who presented as severe acute respiratory illness with high D-dimer levels. All of them on detailed investigation were diagnosed as having PTB and COVID-19 negative.


  Case Series Top


We have included six patients who presented to us as severe acute respiratory illness (SARS) [Table 1]. All were between 11 and 17 years of age. The duration of fever was 3–4 days on an average except in one [patient-3, [Table 1]] case in which fever was on and off for the last 6 months. Onset of difficulty in breathing was 1 or 2 days before admission in all. Five patients had no significant prior illness, whereas one patient was a known case of diabetes mellitus [Patient-6, [Table 1]]. Two out of six [Patient-2 and 6, [Table 1]] had a history of Koch's contact in family. None had exposure to symptomatic/asymptomatic person with novel coronavirus infection.
Table 1: Clinical characteristics of all patients

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In view of current pandemic of COVID-19 (SARS CoV-2), they all were first suspected as having SARS COVID pneumonia and primary treatment was started in form of oxygen therapy along with first-line antibiotic and other supportive and symptomatic management.

On investigation, 5 out of 6 had normal total leukocyte count with neutrophilic predominance (neutrophil-to-lymphocyte ratio [NLR] >3). One patient [patient-1, [Table 1]] has mild increase in leukocyte count with 80% neutrophils (NLR 8). D-dimer levels were high (normal 200–400 ng/ml) in all patients, being significantly high (>1000 ng/ml) in four out of six [patient 1, 4, 5, 6, [Table 1]] patients. Initial coagulation profile (prothrombin time and activated partial thromboplastin time) and renal function tests were normal in all six patients. Four out of six patients had chest X-ray findings suggestive of acute respiratory distress syndrome (ARDS) [Figure 1]a, one patient had predominant single lung involvement in form of diffuse peripheral opacities and the other patient [patient-3, [Table 1]] had chest X-ray suggestive of miliary spread of TB [Figure 1]b. High-resolution computed tomography (HRCT) thorax was done in four out of six patients and findings suggestive of TB in form of tree in bud appearance/consolidation along with cavitatory lesions and enlargement of mediastinal lymph nodes were seen [Figure 2]a, [Figure 2]b and [Figure 2]c. CT pulmonary angiography (CTPA) was done in one patient [Patient-6, [Table 1]] which was normal [Figure 2]d. All six patients tested negative for novel coronavirus (SARS CoV-2). A repeat sample was sent in two patients with a high suspicion of having COVID pneumonia which also came negative for the same. Keeping in consideration, other systemic findings and supportive laboratory evidences in form of sputum cartridge based nucleic acid amplification test, Monteux test, ultrasound abdomen all were diagnosed as having PTB with one patient [patient-5, [Table 1]] also having abdominal TB (disseminated TB). Two out of six patients who had presented with severe respiratory distress required ventilatory care and could not survive in spite of our best efforts [patient 1 and 2, [Table 1]]. One [patient-2, [Table 1]] of them had sudden deterioration in 12 h in both clinical and radiological picture [Figure 3]. Out of rest four, three patients required high flow oxygen therapy for 3–4 days. Low-molecular-weight heparin (LMWH) was given to patients with initial high d-dimer levels along with injection methylprednisolone.[1] to those presented as severe ARDS, with subsequent reports showing decline in d-dimer levels along with improvement in the clinical picture. All four patients who survived were discharged on anti-tuberculous treatment.
Figure 1: (a) X-ray showing acute respiratory distress syndrome on admission. (b) Military tuberculosis

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Figure 2: (a) High-resolution computed tomography of the thorax showing multiple homogenous ground-glass opacities along with pneumomediastinum (b) similar image with a cavity (c) computed tomography of the thorax showing cavitatory lesions (d) computed tomography pulmonary angiography of the same patient showing normal filling of the vessels

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Figure 3: X-ray 1: X-ray on admission showing consolidation with cavity. X-ray 2: 12 h after admission showing rapid deterioration and developing acute respiratory distress syndrome

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  Discussion Top


PTB is very prevalent in developing countries. Estimated incidence of TB in India in 2018 was 2.69 million (199/100,000 population.[2] One study in adults showed series of five patients with different forms of TB presenting with pulmonary embolism having no risk factor for hypercoagulability.[3] Kwas et al. reported three cases of pulmonary embolism associated with severe PTB.[4] Turken et al. and others describes the hemostatic changes along with inflammation leading to hypercoagulable state in severe PTB which improves with treatment. They compared various hematological parameters in severe PTB versus that of control.[5] Although not common, TB especially severe pulmonary/disseminated is at risk for venous thrombosis.[6] Goncalves et al. presented two case reports where two adult patients had thromboembolic events following severe PTB.[7] One recent study recommended the use of prophylactic LMWH in patients with COVID-19 pneumonia presented with high d-dimer levels on admission or sudden clinical worsening which was attributed to pulmonary embolism.[8] They also recommended doing CTPA in place of noncontrast CT when possible to document pulmonary embolism in such patients.[8] A study related to radiographic appearance and patterns of progression revealed predominant peripheral location, common progression pattern from unilateral focal air-space opacity to unilateral multifocal or bilateral involvement during treatment, and lack of cavitation, lymphadenopathy, and pleural effusion as the more distinctive radiographic findings of SARS.[9] Our cases presented with a picture like SARS initially leading to a high suspicion of COVID pneumonia which on HRCT thorax showed few findings suggestive of basic etiology as TB, in form of consolidation with cavitatory changes and enlargement of lymph nodes.


  Conclusion Top


Our case series shows that TB can present as pulmonary embolism in adolescents which presents clinically as severe acute respiratory distress. This is the first case series reporting pulmonary embolism as the presentation of TB in children. In the era where we are attributing novel coronavirus as cause of majority of SARS cases, it is necessary to investigate such cases for underlying tubercular etiology so that early treatment can be initiated in form of antitubercular treatment along with anticoagulants and steroids when needed.

Limitations

As ours is resource-limited setting, we do not have facility in our set up for the confirmatory diagnostic tests of pulmonary embolism like pulmonary angiography, planar V/Q scan (ventilation/perfusion scintigraphy), V/Q single-photon emission computed tomography, etc., None of the same was done for confirmation, which remains a limitation of our study.

Acknowledgment

We are thankful to the department of radiology for providing excellent reporting of HRCT and CTPA images.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Meduri GU, Golden E, Freire AX, Taylor E, Zaman M, Carson SJ, et al. Methylprednisolone infusion in early severe ARDS: Results of a randomized controlled trial. Chest 2007;131:954-63.  Back to cited text no. 1
    
2.
World Health Organization. (2018). Global Tuberculosis Report 2018. World Health Organization. 2018. Available from: https://apps.who.int/iris/handle/10665/274453.  Back to cited text no. 2
    
3.
Mohan B, Kashyap A, Whig J, Mahajan V. Pulmonary embolism in cases of pulmonary tuberculosis: A unique entity. Indian J Tuberc 2011;58:84-7.  Back to cited text no. 3
    
4.
Kwas H, Habibech S, Zendah I, Elmjendel I, Ghedira H. Pulmonary embolism and tuberculosis. Asian Cardiovasc Thorac Ann 2014;22:487-90.  Back to cited text no. 4
    
5.
Turken O, Kunter E, Sezer M, Solmazgul E, Cerrahoglu K, Bozkanat E, et al. Hemostatic changes in active pulmonary tuberculosis. Int J Tuberc Lung Dis 2002;6:927-32.  Back to cited text no. 5
    
6.
Suárez Ortega S, Artiles Vizcaíno J, Balda Aguirre I, Melado Sánchez P, Arkuch Saade ME, Ayala Galán E, et al. La tuberculosis como factor de riesgo de trombosis venosa [Tuberculosis as risk factor for venous thrombosis]. An Med Interna 1993;10:398-400.  Back to cited text no. 6
    
7.
Goncalves IM, Alves DC, Carvalho A, do Ceu Brito M, Calvario F, Duarte R. Tuberculosis and Venous Thromboembolism: A case series. Cases J 2009;2:9333.  Back to cited text no. 7
    
8.
Rotzinger DC, Beigelman-Aubry C, von Garnier C, Qanadli SD. Pulmonary embolism in patients with COVID-19: Time to change the paradigm of computed tomography. Thromb Res 2020;190:58-9.  Back to cited text no. 8
    
9.
Wong KT, Antonio GE, Hui DS, Lee N, Yuen EH, Wu A, et al. Severe acute respiratory syndrome: Radiographic appearances and pattern of progression in 138 patients. Radiology 2003;228:401-6.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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