key: cord-0965673-jo50mddx authors: Goussard, Pierre; Solomons, Regan S.; Andronikou, Savvas; Mfingwana, Lunga; Verhagen, Lilly M.; Rabie, Helena title: COVID‐19 in a child with tuberculous airway compression date: 2020-07-14 journal: Pediatr Pulmonol DOI: 10.1002/ppul.24927 sha: f0adb5ef15b1c1e75d2ede2e6a36f7a4fe273920 doc_id: 965673 cord_uid: jo50mddx nan The rapid global spread of coronavirus disease 2019 (COVID-19) is now well-known with the first case in South Africa on 5 March 2020, 1 and since then, the country has been experiencing a persistent increase in the number of positive cases. By 24 May 2020, there were 99 433 confirmed cases in Africa where the tuberculosis (TB) incidence is 231/100 000. 2, 3 There is uncertainty of the impact of possible dual epidemics of TB and COVID-19 and whether tuberculous lung disease would be a risk factor for severe COVID-19. We describe the first recorded case of COVID-19 coinfection in a young child with airway compression due to Mycobacterium tuberculosis (MTB). Coinfection with other pathogens has been described in up to 40% of children with COVID-19, including influenza A and B, mycoplasma, respiratory syncytial virus, and cytomegalovirus. 4 This is the first report of coinfection with MTB. Airway obstruction due to MTB is known to be complicated by a viral infection, causing additional inflammation, thereby worsening the obstruction. 5 BCG vaccination confers decreased risk of severe childhood TB disease in high-burden areas, an effect negated by low vaccine coverage. 6 Besides protection against TB, BCG vaccination also modulates the immune response to subsequent infections caused by other pathogens, including viruses, by the induction of innate immunity and heterologous lymphocyte activation. 7, 8 In this case, the question raised is whether lack of BCG vaccination increased susceptibility to severe pulmonary TB, COVID-19, and possibly other viral coinfection. The protective effects of BCG vaccination against severity and poor outcome in COVID-19 infection is currently a subject of clinical trials. 9 This case highlights the difficulty that diagnosis and management of COVID-19 presents to clinicians in resource-constrained countries with high TB and HIV burden. This child, known with PTB, presented with clinical symptoms that could have been presumed to be related due to either TB or COVID-19. Routine management of children with significant airway obstruction is also compromised due to the risk bronchoscopy may hold. The nonspecific clinical and radiological findings of COVID-19 in children complicate recognition. Computed tomography (CT) findings are thought to be more specific, 4 but in TB endemic countries, CT scans are not easily available. In patients with complicated PTB, with extensive parenchymal involvement, it would be impossible to differentiate from COVID-19, based on symptoms and chest radiograph findings alone. Bronchoscopy has been used to confirm and determine the severity of tuberculous airway obstruction in children, guiding the decision either to treat medically with antituberculous drugs and oral prednisone or intervene surgically. 10 As bronchoscopy is a very high-risk aerosol-generating medical procedure, in TB endemic areas, this has to be performed with strict indications and with full personal protective equipment (PPE). 11 The indications for bronchoscopy in pediatric TB may need to be revised as full PPE, although optimal, is not always available in a resource-constrained world and may be limited to only N95 masks. Currently, it would be very difficult to predict whether PTB in children confers additional risk of developing severe COVID-19. This case illustrates that children with confirmed PTB may have persistent or worsening symptoms due to other viral infections, including COVID-19 infection, and may present with new pneumonia and exacerbation of TB-associated nodal airway obstruction. However, the rapid improvement is reassuring. The child experienced short-term deterioration of his airway obstruction due to COVID-19, which subsequently rapidly improved. Oral prednisone at 2 mg/kg for TB airway obstruction was continued for 1 month even after recovery from COVID-19. F I G U R E 1 A, A supine frontal chest radiograph was performed as a portable examination. There is confluent air-space disease in the right upper and middle lobes with a small focus of breakdown (white arrow) and airway narrowing at the left main bronchus and the bronchus intermedius (black arrows), which represent surrogate markers of hilar and mediastinal lymphadenopathy. In conjunction with the air-space disease, the parenchymal breakdown and airway narrowing support a diagnosis of primary pulmonary tuberculosis, which was confirmed using Gene Xpert on a gastric washing sample. B, Lateral radiograph confirms the area of parenchymal breakdown (black arrow), presumably in the right middle lobe, and also confirms the lymphadenopathy (white arrows) posteroinferiorly to the bronchus intermedius The effect of corticosteroid and possible impact of BCG vaccination in these children also requires better description. REFERENCES 1. National Institute of Communicable Diseases World Health Organization Regional Office for Africa Clinical and CT features in pediatric patients with COVID-19 infection: different points from adults Airway involvement in pulmonary tuberculosis Global shortages of BCG vaccine and tuberculous meningitis in children Non-specific effects of BCG vaccine on viral infections Bacille Calmette-Guérin (BCG) vaccine and the COVID-19 pandemic : responsible stewardship is needed. The Union. 2020;1-6 World Health Organization. Bacille Calmette-Guérin (BCG) vaccination and COVID-19: scientific brief The role of bronchoscopy in the diagnosis and management of pediatric pulmonary tuberculosis American Association for Bronchology and Interventional Pulmonology (AABIP) statement on the use of bronchoscopy and respiratory specimen collection in patients with suspected or confirmed COVID-19 infection The authors wish to acknowledge Dr. Janette Verster with her help in reviewing this manuscript. The authors declare that there are no conflict of interests.