COVID-19 and Mycobacterium coinfection in Brunei Darussalam: case series

@#Coronavirus disease (COVID-19) and tuberculosis (TB) coinfection is expected to become more common in countries where TB is endemic, and coinfection has been reported to be associated with less favourable outcomes. Knowing about the manifestations and outcomes of coinfection is important as COVID-19 becomes endemic. During the second wave of the COVID-19 pandemic in Brunei Darussalam, we encountered seven patients with COVID-19 and Mycobacterium coinfection. Cases of coinfection included three patients with newly diagnosed pulmonary Mycobacterium infection (two cases of pulmonary TB [PTB] and one case of Mycobacterium fortuitum infection) and four patients who were already being treated for TB (three cases of PTB and one case of TB lymphadenitis). Among the new cases, one had previously tested negative for PTB during a pre-employment medical fitness evaluation and had defaulted from follow up and evaluation. One case died: a 42-year-old man with diabetes mellitus, chronic kidney disease and hypertension who had severe COVID-19 and needed urgent dialysis and supplemental oxygen. All other patients recovered from COVID-19 and completed their TB treatment.

A rare presentation of Mycobacterium africanum after two decades: a case report from Brunei Darussalam

@#Mycobacterium africanum is endemic to West Africa and is rare outside this region. Most of the people infected with M. africanum outside Africa are migrants from affected parts of Africa. We report a rare case of pulmonary tuberculosis (TB) secondary to M. africanum in a man in Brunei Darussalam who had lived and worked in Guinea, West Africa for 6 years more than 20 years ago. He had been well until December 2020, when he presented with a chronic cough and was diagnosed with coinfections of Klebsiella pneumoniae and M. africanum, and newly diagnosed diabetes mellitus. This case highlights an interesting manifestation of pulmonary TB secondary to M. africanum in a patient whose last exposure was 20 years ago, contributed to by development of diabetes mellitus.

Pulmonary tuberculosis and melioidosis coinfection in Brunei Darussalam: the importance of awareness and screening

@#Both tuberculosis (TB) and melioidosis are endemic to certain parts of the world, including Brunei Darussalam, with TB being more widespread. Despite this, coinfection with TB and melioidosis is rarely encountered and reported. Although still uncommon, there has been an increase in the number of cases of this coinfection reported during the past 10 years, all of which have been in India and the World Health Organization’s Western Pacific Region. We report a case of coinfection with pulmonary TB and melioidosis in a patient with poorly controlled diabetes mellitus. This 64-year-old man presented with symptoms and radiological features of pulmonary TB, confirmed by sputum smear, but sputum culture also yielded Burkholderia pseudomallei, the pathogen that causes melioidosis. Coinfection was detected due to our practice of routinely screening for other infections in patients suspected or confirmed to have pulmonary TB. This highlights the importance of awareness of melioidosis and the need to consider screening for infection, especially in endemic regions.

Tuberculosis: a mimicker of malignancy

Tuberculosis infection remains an important cause of mortality. The clinical and radiological manifestations can be non-specific and resemble many other conditions, including malignancies. This could lead to diagnostic delay. We report the case of a 48-year-old woman with tuberculosis presenting with a right upper lobe mass manifesting as metastatic lung cancer. She also had liver cirrhosis secondary to chronic hepatitis B infection. She developed hepatitis two weeks into her tuberculosis treatment. Our case highlights the importance of considering tuberculosis in patients suspected to have underlying malignancy and to be aware of the potential adverse effects of treatment.

A painless chest swelling

A 41-year-old Indonesian lady, non-diabetic, immune-competent, presented with complaints of painless swelling at the lower end of the neck, increasing in size for the past two months. There was history of cough with scanty expectoration for the past one year with insignificant loss of appetite and weight. Local examination showed a 4.5 cm × 6 cm fluctuating non-tender swelling with erythematous overlying skin but no draining point (Panel). On general examination there is no clubbing or lymphadenopathy. Respiratory examination revealed few crepitations over the right infra-clavicular area. Rest of the systemic examination is unremarkable. Her blood investigations showed elevated erythrocyte sedimentation rate (ESR) of 46 mm/hr. Full blood count, liver profiles and renal functions were all normal. A chest radiography was taken. Q: What is the diagnosis? Answer: refer to page 113

A painless chest swelling - Answers

(Refer to page 99) Answer: Tubercular cold abscess The patient’s chest radiography is shown in panel showing right upper zone consolidation. Sputum examination were all negative. Bronchoscopy showed a mass partially obstructing the anterior segment of right upper lobe bronchus. Biopsy revealed multiple multinucleated granulomas and Langhans giant cells with areas of caseation and Acid Fast Bacilli (AFB) on Zeil-Neelsen staining. The patient responded to anti-tubercular treatment (ATT).