Reactions 1871, p148 - 4 Sep 2021
Dimethyl fumarate S
COVID-19 respiratory infection and Mycobacterium tuberculosis infection: case report
A 20-year-old woman developed COVID-19 respiratory infection and Mycobacterium tuberculosis infection during immunosuppressant drug therapy with dimethyl fumarate for multiple sclerosis.
The woman had been receiving immunosuppressant drug therapy with dimethyl fumarate 240mg two times per day for the previous 1-year [route not stated]. She presented with a history of fever, productive cough of one month duration, weight loss and fatigue. Although, she had no history suggestive of contact with COVID-19 positive patient, she was diagnosed with COVID-19 by real time-PCR (RT-PCR). Upon presentation, physical examination revealed peripheral oxygen saturation of 95% on room air, BP of 70/56mm Hg and respiratory rate of 20 cycles/min. Chest examination showed crepitations in the right mammary area. Chest X-ray exhibited right upper and mid-zone non-homogenous opacity. She tested negative for HIV. She was admitted to COVID-19 ICU. In the COVID-19 ICU, IV dexamethasone was started along with unspecified inotropes and antibiotics along with other supportive care. However, considering the history of weight loss, location of the opacity in chest X-ray and background medication history, pulmonary tuberculosis was suspected. Sputum tested positive for acid-fast bacilli (AFB). Cartridge-based nucleic acid amplification test (CBNAAT) confirmed the mycobacterium tuberculosis infection, sensitive to rifampicin [not all times to reaction onsets stated].
The woman started receiving standard four drug antitubercular regimen containing weight adjusted doses of rifampicin, isoniazid, ethambutol and pyrazinamide. Dimethyl fumarate was continued. During the hospital stay(10 days), she did not exhibited any adverse effects to the treatment. Inotropes were tapered and discontinued. She needed supplemental oxygen via face mask. Over the subsequent 12h, the saturation improved to 95% and supplemental oxygen supply was tapered and stopped. She was closely monitored for adverse effects even after she was discharge. By the end of intensive phase of 2 months, she had gained 6kg of weight.
All symptoms had subsided. However, her sputum CBNAAT continued showed presence of tuberculosis bacillus. No resistance to rifampicin was detected. Further testing with Line Probe Assay confirmed the absence of resistance to both isoniazid and rifampicin.
At the end of 6 months of the therapy, her sputum was negative for AFB. She has gained 8kg of weight in total. All chest findings were subsided [not all outcomes stated].
Jacob J, et al. Coinfection of SARS-CoV-2 and MTB: how not to miss the wood for the trees. BMJ Case Reports 14: No. 7, 13 Jul 2021. Available from: URL: http://
doi.org/10.1136/bcr-2020-240581 803592417
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