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Simultaneous Evaluation of the Clinical Epidemiology of Tuberculosis and Coronavirus Disease 2019 in Patients Admitted to the Fifth Azar Educational-Therapeutic Center in Gorgan, Iran (2020-2022)
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Matin Zafar Shokourzadeh1    , Ebrahim Kouhsari*2 , Taghi Amiriani3 , Ali Asghar Ayatollah *4 |
1- M.Sc in Medical Laboratory Sciences, Research Center of Medical Laboratories, Faculty of Paramedicine, Golestan University of Medical Sciences, Gorgan, Iran.
2- Assistant Professor of Medical Laboratory Sciences, Center for Medical Laboratory Research, Faculty of Paramedicine, Golestan University of Medical Sciences, Gorgan, Iran. ekouhsari1987@gmail.com
3- Professor of Adult Gastroenterology and Hepatology, Research Center of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan, Iran.
4- Academic Instrctor, Center for Research in Laboratory Sciences, Department of Medical Laboratory Sciences, Faculty of Paramedical Sciences, Golestan University of Medical Sciences, Gorgan, Iran. , ayatollahilab@gmail.com |
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Keywords: Tuberculosis [MeSH], COVID-19 [MeSH], Coinfection [MeSH]
Article ID: Vol27-25 |
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Type of Study: Original Articles |
Subject:
Infectious Medicine
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Abstract: (8 Views) |
Extended Abstract
Introduction
Tuberculosis (TB) and coronavirus disease 2019 (COVID-19) co-infection has emerged as an urgent global public health concern. The rapid spread of the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has strained healthcare systems and reversed years of progress in the fight against TB.
The COVID-19 pandemic has had a significant impact on TB detection, with reports indicating a reduction in the diagnosis of new TB cases and the administration of TB vaccinations. Furthermore, the COVID-19 pandemic has been associated with the reactivation of latent TB and an increased susceptibility to TB infection.
Studies have indicated that TB can contribute to more severe COVID-19 infection. According to a World Health Organization (WHO) report, which included data from 84 countries, it was estimated that 1.4 million fewer people received TB treatment in 2020 compared to 2019, representing a 21% reduction in access to treatment due to COVID-19. Further data showed an additional 18% decline in treatment access in 2021 compared to 2020. As a result of this disruption in TB care, the WHO projected that between 200,000 and 400,000 additional TB deaths would occur worldwide in 2020, with the likelihood of this excess mortality increasing relative to the previous year.
The management of TB and COVID-19 co-infection necessitates tailored treatment strategies. This is due to potential drug interactions and the fact that the presence of COVID-19 may exacerbate the TB-associated lung damage. The prolonged fibrotic injury caused by COVID-19 raises questions regarding whether co-infection of individuals with latent TB and SARS-CoV-2 leads to excessive fibrosis in the lungs and the emergence of active TB infection.
Currently, there are limited data available on the prevalence and long-term consequences of TB and COVID-19 co-infection in Iran, and specifically in Golestan Province. Therefore, this study was conducted to simultaneously evaluate the clinical epidemiology of TB and COVID-19 in patients admitted to the Fifth Azar Educational-Therapeutic Center in Gorgan, Iran.
Methods
This retrospective, descriptive-analytical study was performed on 22 patients (12 men and 10 women) with active or old TB and COVID-19 admitted to the Fifth Azar Educational-Therapeutic Center in Gorgan, Iran, during 2020-2022.
COVID-19 diagnosis was conducted based on the WHO interim guidance. Only laboratory-confirmed cases were included in the study. Patients were diagnosed clinically (based on lung radiographic features) and were also confirmed using laboratory data (real-time polymerase chain reaction (RT-PCR) of nasopharyngeal swab specimens from the upper respiratory tract, as well as tracheal aspirate specimens). Finally, the required information was extracted and recorded from patients’ records in the hospital and compiled into a checklist. Clinical samples that were culture-positive or smear-positive for TB, or cases reported as TB in the patients' records, were also extracted and recorded from the records available in the hospital. The necessary data were collected and categorized using a questionnaire. This questionnaire comprised demographic characteristics (age and gender), a history of cigarette smoking, the type of culture sample, clinical symptoms (fever, chest pain, and upper respiratory tract infection symptoms), and underlying diseases (myocardial infarction, cardiovascular accidents, hyperlipidemia, hypertension, diabetes, hepatic failure, renal failure, cardiopulmonary, gastrointestinal, and endocrine problems, neoplasm, immune deficiency in recipients of corticosteroids and organ transplants, and a history of infectious diseases (COVID-19 and human immunodeficiency virus [HIV]). Laboratory parameters were collected and classified by reviewing patients’ records, the hospital information system, and laboratory data.
Results
Out of a total of 22 patients, 13 were deceased and 9 recovered. The median age of the patients was 70 years. Eight patients (36%) were admitted to the intensive care unit (ICU), 8 (36%) to the respiratory isolation ward, 5 (23%) to the infectious diseases ward, and one (4.5%) to the surgery ward. All patients admitted to the ICU died, which accounted for 61.53% of the total deaths.
The mean age of the recovered group was determined to be 69 years (age range = 26-71 years). In contrast, the mean age of the deceased group was determined to be 75 years (age range = 58-84 years).
Dyspnea was observed in 18 out of 22 patients (13 deceased and 5 recovered) (P<0.017). Other symptoms included cough (n=14), weakness (n=9), fever (n=9), chest pain (n=3), abdominal pain (n=2), bloody discharge (n=2), dizziness (n=1), nausea and vomiting (n=1), and muscle cramps (n=1). While no statistically significant difference was found between the recovered and deceased groups in the radiological findings, characteristics, such as multiple mottling and ground-glass opacity, were observed in 46% of the deceased patients. Crazy paving was also observed in 46%, bilateral patchy shadowing in 38%, consolidation in 38%, and cavitation in 18% of the deceased.
The mean alanine aminotransferase (ALT) level in the deceased group (38 IU/L) showed a statistically significant increase compared to the recovered group (15 IU/L), (P<0.019). Similarly, the mean blood urea nitrogen (BUN) level in the deceased group (35 IU/L) showed a statistically significant increase compared to the recovered group (15 IU/L), (P<0.004). The mean (and normal range) laboratory results for prothrombin time (PT) (D = 14.40 seconds) and international normalized ratio (INR) (D = 1.27 seconds) in the deceased group were slightly higher, but non-significantly, compared to the recovered group. Partial thromboplastin time (PTT) values were also approximately similar between the deceased and recovered groups. No significant difference was found between the recovered and deceased groups in the levels of direct bilirubin, total bilirubin, alkaline phosphatase (ALP), calcium (Ca), sodium (Na), creatine phosphokinase (CPK), creatinine (Cr), fasting blood sugar (FBS), potassium (K), and phosphorus (P).
In the deceased and recovered groups, the mean white blood cell (WBC) count (15 and 8 (9^10/L); P<0.008), the mean corpuscular hemoglobin concentration (MCHC) (33.01 g/dL and 31.81 g/dL; P<0.014), and the mean C-reactive protein (CRP) (35 mg/L and 16 mg/L; P<0.042) showed a statistically significant increase, respectively. Furthermore, the mean hemoglobin (Hb) (9.90 g/dL and 11.10 g/dL; P<0.045) and the mean hematocrit (Hct) (30% and 35%; P<0.006) showed a statistically significant decrease in the deceased and recovered groups, respectively.
Conclusion
Based on the results of this study, a higher probability of death was observed in patients with TB and COVID-19 co-infection who experienced dyspnea and ICU admission, along with elevated laboratory values of ALT and BUN.
The common symptom in patients with respiratory infections is difficulty breathing or a sensation of not getting enough air. In the present study, all 13 deceased patients experienced dyspnea, and this finding was determined to be 56% in recovered patients. This finding suggests that dyspnea may be an important indicator of poorer outcomes in patients with TB and COVID-19
co-infection. The presence of dyspnea can reflect a more severe respiratory infection or the development of complications, such as pneumonia or acute respiratory distress syndrome (ARDS), which can lead to an increased risk of mortality. Monitoring symptoms, such as dyspnea, and providing appropriate interventions can be vital in the management of TB and COVID-19
co-infection.
ALT is an enzyme primarily found in the liver. A statistically significant difference was observed in deceased patients with higher ALT compared to recovered patients in the present study. The median BUN level was reported as 15 mg/dL in the recovered group, whereas it was determined to be 35 mg/dL in the deceased group.
Elevated ALT levels can indicate liver injury or dysfunction and may be associated with poorer outcomes in patients with TB and COVID-19 co-infection. High ALT levels can have various etiologies, such as drug-induced liver injury, viral hepatitis, or other liver-related complications.
BUN levels can be indicative of renal function and dehydration. A significant decrease was observed in BUN levels in the recovered group compared to the deceased group. Elevated BUN levels may be associated with poorer outcomes in patients with TB and COVID-19 co-infection. Renal dysfunction can be caused by various factors, such as acute kidney injury, chronic kidney disease, or drug-induced nephrotoxicity.
Altered hematological parameters, including WBC, MCHC, Hb, and Hct, may be associated with TB and COVID-19 co-infection. Elevated WBC count can indicate a more severe infection or inflammation. Increased inflammation can culminate in tissue damage and dyspnea, resulting in worse outcomes in some patients. Meanwhile, changes in MCHC, Hb, and Hct levels can be indicative of impaired oxygen-carrying capacity and the occurrence of worse outcomes. These parameters are interrelated and reflect the blood's oxygen-carrying capacity. Reduced levels of MCHC, Hb, and Hct can be indicative of anemia, which compromises oxygen delivery to tissues and organs, exacerbating respiratory problems and worsening the prognosis in patients with TB and COVID-19 co-infection. Moreover, both TB and COVID-19 can affect hematopoiesis (blood cell formation) and nutritional status, giving rise to alterations in WBC count, Hb, and other hematological parameters.
Ethical Statement
This study was approved by the Research Ethics Committee of Golestan University of Medical Sciences (IR.GOUMS.REC.1402.261).
Funding
This article has been extracted from a research project (No. 113486) approved by the Laboratory Sciences Research Center.
Conflicts of Interest
No conflict of interest.
Acknowledgments
We would like to thank the healthcare staff, nurses, clinical personnel, and all individuals who dedicated themselves to the fight against the COVID-19 pandemic, as well as the Clinical Research Development Unit of the Fifth Azar Educational-Therapeutic Center in Gorgan, Iran, for their cooperation in the execution of this study.
Authors' Contributions
Matin Zafar Shokourzadeh: Project execution, Data collection.
Ebrahim Kouhsari (Ph.D): Project administration and design, Interpretation of the results, Drafting of the initial manuscript, Approval of the final manuscript.
Taghi Amiriani (M.D): Project administration and design.
Ali Asghar Ayatollah (M.Sc): Project administration and design, Approval of the final manuscript.
Key Message: The probability of death is higher in patients with TB and COVID-19 co-infection who experience dyspnea, require ICU admission, and have increased ALT and BUN laboratory values.
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Zafar Shokourzadeh M, Kouhsari* E, Amiriani T, Ayatollah A A. Simultaneous Evaluation of the Clinical Epidemiology of Tuberculosis and Coronavirus Disease 2019 in Patients Admitted to the Fifth Azar Educational-Therapeutic Center in Gorgan, Iran (2020-2022). J Gorgan Univ Med Sci 2025; 27 (3) :39-47 URL: http://goums.ac.ir/journal/article-1-4545-en.html
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