




































    

 American Journal of Medical and Physical Education  

Vol.9, Issue 1; January-February 2024; 

ISSN: 2994-0524 

Impact Factor: 6.14 

1252 Columbia Rd NW, Washington DC, United States 

https://topjournals.org/index.php/AJMPE; mail: topacademicjournals@gmail.com 

 
 

 

 

1 | A m e r i c a n  J o u r n a l  o f  M e d i c a l  a n d  P h y s i c a l  E d u c a t i o n  

|  https://topjournals.org/index.php/AJMPE 

FROM SILENCE TO RESURGENCE: TUBERCULOSIS REACTIVATION 

FOLLOWING COVID-19 – A SINGULAR CASE ANALYSIS 

 

 
1Nino G. Javakhishvili, 2David L. Kipshidze and 3Mariam N. Abashidze 
1Department of Infectious Disease, Tbilisi State Medical University, Tbilisi, Georgia 
2Intensive Care Unit, Tbilisi State Medical University, Tbilisi, Georgia  
3Department of Neurology, Tbilisi State Medical University, Tbilisi, Georgia.   

DOI: https://doi.org/10.5281/zenodo.10598098 
 

 

Abstract: Tuberculosis (TB) stands as a prominent global health threat, persisting as a leading cause of mortality 

on a worldwide scale (World Health Organization, 2022a). Caused by the infectious agent Mycobacterium 

tuberculosis, TB spreads through respiratory droplets when an infected individual coughs or sneezes. While 

primarily affecting the lungs, TB can extend its impact to various organs and systems within the body (Centers 

for Disease Control and Prevention, 2022). 

This research aims to shed light on the diverse facets of TB, focusing on its two principal manifestations: latent 

TB infection and active TB disease. Latent TB infection characterizes individuals who carry the TB bacteria but 

remain asymptomatic and do not transmit the disease. However, the latent form poses a risk of progressing into 

active TB disease, particularly in cases where the individual's immune system becomes compromised (Centers 

for Disease Control and Prevention). 

The urgency of addressing TB is underscored by its potential to transition from latent to active, thereby elevating 

the risk of transmission and severe health consequences. The study delves into the dynamics of TB infection, 

emphasizing the critical importance of early detection and intervention to mitigate the escalation from latent to 

active TB. Furthermore, it explores factors contributing to the weakening of the immune system, which serves as 

a pivotal link between latent TB and the development of active disease. 

By elucidating the intricate interplay between latent and active TB, this research not only contributes to a deeper 

understanding of the disease but also provides insights crucial for public health strategies and interventions. The 

overarching goal is to inform targeted measures that can effectively curb the spread of TB and reduce its impact 

on global health. 

Keywords: Tuberculosis (TB), Latent TB Infection, Active TB Disease, Mycobacterium tuberculosis, Immune 

System Compromise 

 

INTRODUCTION 

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 American Journal of Medical and Physical Education  

Vol.9, Issue 1; January-February 2024; 

ISSN: 2994-0524 

Impact Factor: 6.14 

1252 Columbia Rd NW, Washington DC, United States 

https://topjournals.org/index.php/AJMPE; mail: topacademicjournals@gmail.com 

 
 

 

 

2 | A m e r i c a n  J o u r n a l  o f  M e d i c a l  a n d  P h y s i c a l  E d u c a t i o n  

|  https://topjournals.org/index.php/AJMPE 

Tuberculosis (TB) is a significant global health concern and remains one of the leading causes of death worldwide 

(World Health Organization, 2022a). It is an infectious disease caused by the Mycobacterium tuberculosis. TB is 

spread through the air when an infected person coughs or sneezes. It primarily affects the lungs, but can also affect 

other parts of the body (Centers for Disease Control and Prevention, 2022).   

TB can present in two main forms: latent TB infection and active TB disease. Latent TB infection occurs when a 

person has been infected with the TB bacteria but does not yet have active disease or symptoms. In this case, the 

bacteria are dormant and cannot be spread to others. However, people with latent TB infection are at risk of 

developing active TB disease if their immune system becomes weakened (Centers for  Disease  Control  and 2          

Med. Case Stud.  

Prevention, 2022). COVID-19 infection can increase the risk of TB reactivation due to a combination of factors. 

These factors include immune system suppression, as well as disruptions to TB diagnosis, treatment, and 

prevention services (World Health Organization, 2022b).  

Tuberculous meningitis (TBM) is one of the most severe manifestations of extrapulmonary TB. CNS-TB 

represented the 13.91% of all cases of meningitis and 4.55% of all cases of TB (Navarro-Flores et al., 2022). The 

pathophysiology is primarily driven by three components, which also explain the clinical symptoms (Rich and 

McCordock, 1933; Dastur et al., 1995). Thick gelatinous exudate, which is especially apparent at the basal region 

of the brain, eventually produces a fibrous mass that encases nearby structures. As a result, periventricular infarcts 

and cranial nerve palsies are developed. Spasm, constriction, thrombosis, and occlusion of intracerebral arteries 

are all possible effects of tuberculous vasculitis and the concomitant inflammatory vascular changes (Chan et al., 

2005). The intracranial vasculitis is expected to have a major impact on the remaining neurologic deficits (Poltera, 

1977).   

Clinical approach and diagnostic tools, including CSF analysis and radiographic imaging, are equally important 

to diagnose TB meningitis (Lewinsohn et al., 2017). The treatment for tuberculous meningitis is very complex. 

Commonly, the combination of Isoniazid, Rifampin, Pyrazinamide and Ethambutol/Streptomycin/  

Fluoroquinolone is given for an extended period of time. However, sometimes drug resistance is found which 

leads to adjustments in treatment (Donald, 2010; World Health Organization, 2017). This case describes the 

development of tuberculous meningitis in a patient with COVID-19.  

CASE PRESENTATION  

39-year-old male presented to the emergency department on June 4, 2022, with fatigue, fever, shortness of breath, 

nausea, and vomiting. He tested positive for COVID-19. A cardiopulmonary examination showed clear lung fields 

and normal heart sounds. Neurological assessment showed signs of ataxia, vertigo, and horizontal nystagmus; 

however, a head CT scan has not shown any pathological features. Two days later, the patient developed new 

clinical signs, including facial asymmetry with loss of the left nasolabial fold, right-sided ptosis, spontaneous 

rotatory nystagmus, dysphagia, dysarthria, and trouble coordinating. Jaw jerk and gag reflexes were both 

diminished. Reduced deep tendon reflexes were present in all extremities, more so on the left. He also suffered 

from neck rigidity.   

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 American Journal of Medical and Physical Education  

Vol.9, Issue 1; January-February 2024; 

ISSN: 2994-0524 

Impact Factor: 6.14 

1252 Columbia Rd NW, Washington DC, United States 

https://topjournals.org/index.php/AJMPE; mail: topacademicjournals@gmail.com 

 
 

 

 

3 | A m e r i c a n  J o u r n a l  o f  M e d i c a l  a n d  P h y s i c a l  E d u c a t i o n  

|  https://topjournals.org/index.php/AJMPE 

A head MRI revealed hyperintensity in the brainstem and left cerebellum (Figures 1 and 2). CSF analysis revealed 

lymphocytosis, decreased glucose, and elevated protein. Adenosine deaminase  levels  and  CSF PCR for 

tuberculosis were both positive as well.  

Following the lumber puncture, treatment with Dexamethasone, Vancomycin, and Ceftriaxone was started 

immediately due to an increased suspicion of meningitis. After the patient's cerebrospinal fluid results confirmed 

TB meningitis, the treatment regimen was adjusted to Streptomycin, Rifampicin, Isoniazid, Pyrazinamide and 

Dexamethasone.   

The following day, the patient was diagnosed with purulent endobronchitis based on an X-ray and bronchoalveolar 

lavage. Soon after, he developed a cytokine storm and was taken to the intensive care unit, where he was intubated, 

sedated, and mechanically ventilated. Due to a protracted need for breathing support, he underwent tracheostomy 

placement. The patient was taken off the ventilator on July 9th, 2022, but continued to receive oxygen through a 

tracheostomy.  

On August 1, 2022, the patient was discharged with stable vital signs. Oropharyngeal and cardiopulmonary 

examinations revealed no abnormalities. During neurological examination, the patient was spatially and 

temporally oriented and was able to follow simple commands. Pupils were equally round and lightresponsive. 

However, he still displayed dysmetria and Babinski reflex on the left side, along with horizontal nystagmus, as 

residual neurological deficit. The patient was advised to take Rifampicin and Isoniazid for 9 months.   

Ethics section  

Informed consent was obtained from the patient prior to data collection, ensuring their comprehensive 

understanding of the study's objectives, potential implications, and the confidentiality of their sensitive medical 

information. The patient was provided with detailed information about the case report, including its purpose, 

methodology, and the intended use of medical records and clinical details. It was explicitly communicated that 

participation in the study was entirely voluntary, and the patient could opt out at any stage without affecting their 

medical care or rights. Emphasis was placed on the de-identification of all data, ensuring the anonymity of the 

patient. The patient was reassured that the patient's personal and medical information would be treated with the 

utmost confidentiality and solely utilized for the purpose of this case report.  

DISCUSSION  

Based on this case, it is apparent that even a benign case of COVID-19 may eventually lead to severe 

consequences, such as TB reactivation.  The timely identification of early neurological manifestations allowed 

for prompt evaluation and diagnosis of TB meningitis,   

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 American Journal of Medical and Physical Education  

Vol.9, Issue 1; January-February 2024; 

ISSN: 2994-0524 

Impact Factor: 6.14 

1252 Columbia Rd NW, Washington DC, United States 

https://topjournals.org/index.php/AJMPE; mail: topacademicjournals@gmail.com 

 
 

 

 

4 | A m e r i c a n  J o u r n a l  o f  M e d i c a l  a n d  P h y s i c a l  E d u c a t i o n  

|  https://topjournals.org/index.php/AJMPE 

   
Figure 1. MRI revealed hyperintensity in the brainstem.  

   
Figure 2. MRI revealed hyperintensity in the left cerebellum.  

Which prevented further delays in treatment. So, despite the severity and complexity of the presented case, the 

overall outcome was positive. However, it should be mentioned that the patient still developed a residual 

neurological deficit.   

Conclusion  

In conclusion, this case highlights that the potential complications and challenges associated with COVID-19 

infection extend beyond the impact of a single infectious Megrelishvili et al.3  

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 American Journal of Medical and Physical Education  

Vol.9, Issue 1; January-February 2024; 

ISSN: 2994-0524 

Impact Factor: 6.14 

1252 Columbia Rd NW, Washington DC, United States 

https://topjournals.org/index.php/AJMPE; mail: topacademicjournals@gmail.com 

 
 

 

 

5 | A m e r i c a n  J o u r n a l  o f  M e d i c a l  a n d  P h y s i c a l  E d u c a t i o n  

|  https://topjournals.org/index.php/AJMPE 

Agent. The combined effects of multiple factors can significantly affect various organ systems, including the 

nervous system. COVID-19 affects several organ systems, thus any symptom could be attributed to it and 

underlying pathology may go unnoticed. The immune system suppression induced by COVID-19 can increase 

the risk of TB reactivation, thereby complicating diagnosis and treatment.   Therefore, it is crucial to consider the 

possibility of TB reactivation in COVID-19 patients, particularly those from regions with high TB prevalence.  

Therefore, timely detection and prompt treatment of TB are essential to prevent severe complications and improve 

clinical outcomes in these patients.   

CONFLICT OF INTERESTS  

The authors have not declared any conflict of interests.  

REFERENCES  

Centers for Disease Control and Prevention (2022). Tuberculosis (TB). Retrieved from 

https://www.cdc.gov/tb/topic/basics/default.htm  

Chan KH, Cheung RT, Lee R (2005). Cerebral infarcts complicating tuberculous meningitis. Cerebrovascular 

Diseases 19:391.  

Dastur DK, Manghani DK, Udani PM (1995). Pathology and pathogenetic mechanisms in neurotuberculosis. 

Radiologic Clinics of North America 33:733.  

Donald PR (2010). Cerebrospinal fluid concentrations of antituberculosis agents in adults and children. 

Tuberculosis (Edinb) 90:279.  

Lewinsohn DM, Leonard MK, LoBue PA (2017). Official American Thoracic Society/Infectious Diseases Society 

of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of 

Tuberculosis in Adults and Children. Clinical Infectious Diseases 64:e1.  

Navarro-Flores A, Fernandez-Chinguel JE, Pacheco-Barrios N (2022). Global morbidity and mortality of central 

nervous system tuberculosis: a systematic review and meta-analysis. The Journal of Neurology 269:3482.  

Poltera AA (1977). Thrombogenic intracranial vasculitis in tuberculous meningitis. A 20 year "post mortem" 

survey. Acta Neurologica Belgica 77:12.  

Rich AR, McCordock HA (1933). Pathogenesis of tuberculous meningitis. Bulletin of the Johns Hopkins Hospital 

52:5.  

World Health Organization (2017). Guidelines for treatment of drugsusceptible tuberculosis and patient care, 

update. http://apps.who.int/iris/bitstream/10665/255052/1/9789241550000eng.pdf?ua=1 (Accessed on 

June 08, 2017).  

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 American Journal of Medical and Physical Education  

Vol.9, Issue 1; January-February 2024; 

ISSN: 2994-0524 

Impact Factor: 6.14 

1252 Columbia Rd NW, Washington DC, United States 

https://topjournals.org/index.php/AJMPE; mail: topacademicjournals@gmail.com 

 
 

 

 

6 | A m e r i c a n  J o u r n a l  o f  M e d i c a l  a n d  P h y s i c a l  E d u c a t i o n  

|  https://topjournals.org/index.php/AJMPE 

World Health Organization (2022a). Global tuberculosis report 2022. Retrieved 

 fromhttps://www.who.int/publications/i/item/9789240061729  

World Health Organization (2022b). TB disease burden. In Global tuberculosis report 2022. Retrieved from 

https://www.who.int/teams/global-tuberculosis-programme/tbreports/global-tuberculosis-report-2022/tb-

disease-burden/2-2-tbmortality  

 

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