RESULTS
Seven of the eight patients were female (87.5%), and one was male
(12.5%). The median age was 16 (years) (min: 13.5, max: 17). Only one
of the patients was a migrant from Syria (12.5%) and remaining ones
were Turkish.
Fever (75%), cough (75%), side pain (37.5%), and swelling at neck
(12.5%) were most common complaint of the patients at admission. Four
patients had a history of COVID-19 infections. COVID-19 antibody test
was positive at six patients. COVID-19 antibody was negative in only a
patient and the patient had not been tested for COVID-19 because he had
no complaints when his parents with whom they lived in the same house,
were COVID-19 positive. The families reported that none of them had any
complaint and received any therapy for covid-19 infection. There was no
record about their admission to hospital in our national medical
database. Patients were diagnosed as Tb at the based on clinical
findings, imaging studies, PPD test, pathologic examination of biopsy
samples and quantiferon test (Table 1 and Figure 1).
Family screening of all patients was negative, and they had BCG scars.
One of the patients had culture positivity (patient 7) and was not
resistant to first-line drugs. Only a patient had tuberculosis
lenfadenitis as extrapulmonary tuberculosis (patient 6). None of our
patients had CD 4 lymphopenia and their HIV tests were also negative.
Two of the patients had chronic disease. One of them diagnosed as
primary ciliary dyskinesia in our departmant (patient 8) and second one
was following by rheumatology departmant for the diagnosis of juvenile
idiopathic rheumatoid arthritis (JİA). P1, admitted to the pediatric
infectious disease in patient clinic due to a pleural effusion while
receiving TNF-alpha inhibitor for juvenile idiopathic rheumatoid
arthritis (JIA). Since TNF-alpha inhibitor treatment was considered
responsible for the activation of tuberculosis, we stopped the therapy.
The patient had a history of COVID-19 disease which confirmed by PCR. In
spite of appropriate antibiotic treatment and discontinuation of TNF
alpha inhibitor, the effusion did not regress. Pleural biopsy revealed a
necrotizing granulomatous infection (Figure 2). Thus, anti-tuberculosis
therapy including isoniazid, rifampicin, pyrazinamide, ethambutol were
started. Because of JIA, Tb and extended hospitalization in the patient,
immunologic evaluation was performed. His immunological evaluation
revealed hypogammaglobulinemia and low memory B cell. Since the patient
met the diagnostic criteria for primary immunodeficiency according to
ESID, we started IVIG treatment. Almost 6 months after the first COVID19
positive PCR test, the patient admitted to hospital with complaint of
fever and cough for the second time and was found to be COVID-19
positive. Then, he hospitalized and treated. Whole exome sequencing
which was done for suspicion of common variable immunodeficiency showed
an autosomal dominant heterozygous mutation in TNFRSF13B gene (c.204insT
). None of the other patients had an underlying chronic disease.
Immunologic evaluation was done to all 8 patients at the time of
diagnosis due to their severe clinical presentation then expected for
this age group (Table 2). The results are summarized in Table 2. During
the infection, only a patient (patient # 2) had lymphopenia but turn to
normal count at the first month of anti Tb treatment. One patient had
low serum IgG levels (patient # 1). Two patients had borderline low
serum IgG1 levels and one patient had borderline low serum IgM levels
[16]. When the peripheral lymphocyte subset was examined, B cells
were low in only a patient (patient#2), B cell count could not
re-evaluated because the patient did not come to our clinic for
follow-up. Natural killer (NK) cells were low in five patients. We could
check three of our patients with low NK levels, it returned to normal in
patients other than p1 (Table 2).