{'fraction_non_alphanumeric': 0.02448, 'fraction_numerical': 0.01744, 'mean_word_length': 4.7243589743589745, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Can we afford to forget the old killer (tuberculosis) in this COVID-19 pandemic: a case report of scrofula with COVID-19 in a health care worker

In the current scenario of COVID-19 pandemic, we are encountering COVID-19 patients with vague symptoms and in association with many other diseases. We are reporting such a case where neglecting other cause of pyrexia in a patient of COVID-19 would have resulted in disastrous consequences. A young 22 years aged female was admitted to our hospital as COVID-19 with right supraclavicular lymphadenopathy, she was subjected to FNAC of right supraclavicular lymph node. In RT-PCR Mycobacterium Tuberculosis was detected. After three days of starting on Antitubercular drugs she became afebrile. It is important to ensure early diagnosis and continuity of services for tuberculosis along with effective and rapid response to COVID-19 pandemic, so that anticipated increase in TB related deaths during this pandemic can be prevented.


INTRODUCTION
COVID-19 (Corona Virus Disease-19) was first reported from Wuhan city, Hubie Province, China in December 2019. 1 In late December 2019 Wuhan reported clustering of cases of pneumonia of unknown origin. A new virus from family of corona viruses was considered to be the causative agent and was called as novel corona virus initially. Later it was named as Severe Acute Respiratory Syndrome Corona Virus -2 (SARS-CoV-2). On the other side tuberculosis (TB) is one of the oldest documented infectious diseases caused by bacteria Mycobacterium Tuberculosis. Scrofula is the Latin word for brood sow, and it is the term applied to tubercular lymphadenitis of neck. 2

CASE REPORT
We report a case of 22 years old female, student of BSc Nursing at Hoshiarpur, Punjab. She is a resident of Mandi, Himachal Pradesh. During initial phase of lockdown, she returned on 18 th March 2020 to Una, Himachal Pradesh and was in Home quarantine at Una. She had history of fever in last week of April; for this she took some over the counter medications in form of antibiotics and antipyretics. Her fever settled after taking medication. She came back to her native place at Mandi, Himachal Pradesh on 7 th May 2020.
She again developed fever on 15 th May 2020. Temperature was documented up to 103-degree Fahrenheit, associated with chills, sweating without diurnal variation. Her oropharyngeal and nasopharyngeal swabs were taken on 19 th May to rule out COVID-19. As she was tested positive for COVID-19, she was admitted to SLBSGMCH Mandi (COVID dedicated tertiary care center) on 20 th May. She had history of occasional nonproductive cough. There was no history of shortness of breath, sore throat, chills, myalgia, chest pain, loose stools, pain abdomen, headache, anosmia or dysgeusia.
Her past history, personal history, family history and menstrual history was noncontributory.
On admission she had tachycardia, temperature of 103degree Fahrenheit, normal SpO2 and normal respiratory rate. On general physical examination she had right supraclavicular lymphadenopathy (Figure 1). There were multiple firm, non-tender, matted lymph nodes in right supraclavicular fossa. Overlying skin was normal and lymph nodes were not fixed to underlying structures. Rest of the general physical and systemic examination was noncontributory.  (Figure 3 and 4).

DISCUSSION
Much is known about mycobacterium tuberculosis but we have a very little experience with COVID-19. Our patient being a health care worker had risk of exposure to both SARS COV-2 and Mycobcaterium Tuberculosis, she had a travel history from a red zone to green zone 4 days back. Although she had fever about three weeks earlier also for which she could not get a consultation because of nationwide lockdown, so she took some over the counter antibiotics and her fever settled.
As she became symptomatic in form of high-grade fever at her native place after 2 weeks of first episode of fever, she was diagnosed as COVID-19 initially and later as associated EPTB. It has been seen in China and Korea during COVID-19 pandemic as the resources were diverted for COVID-19 it led to disruption of services for tuberculosis. Long distance travel has been prohibited, due to lockdown people could not access health services, health system has collapsed at places of heavy burden of COVID-19 patients, priority is being given to COVID-19 patients in comparison to other diseases. Increased fear among health care workers for COVID-19 led to under reporting of TB patients. In Korea the hospitals built for drug resistant tuberculosis have been used for COVID-19 patients, so there has been serious breach in continuity of TB services, so a spike in TB incidence, given to delayed diagnosis and increased transmission is expected. 7 Similarly, in our case patient could not visit to health care facility due to nationwide lockdown and so was missed during first episode of fever. During second spike of fever, she was again initially managed as COVID-19 only. As for now LAP has not been seen in association with COVID-19 so FNAC of her lymph node was done to look for any association but HPE was suggestive of tubercular picture and also CBNAAT for MTB was also detected, so she was diagnosed to have EPTB also. In this case diagnosis of TB was delayed due to COVID-19 pandemic. She became afebrile on 3 rd day after starting ATT.
Tubercular lymphadenitis of the neck is known as scrofula also, it is caused by tubercular or non-tubercular mycobacterium. It is the presenting form in 5% of the cases. However, in immunocompromised patients one third of the patients may present as scrofula. 8 World health organization (WHO) on its information note on Tuberculosis and COVID-19 pandemic, anticipated that in view of COVID-19 pandemic if there is 25% reduction in detection of tuberculosis globally due to disruption of TB services, it may lead to 13% increase in TB deaths. 9

CONCLUSION
It is important to ensure early diagnosis and continuity of services for tuberculosis along with effective and rapid response to COVID-19 pandemic, so that anticipated increase in TB related deaths during this pandemic can be prevented.

Funding: No funding sources
Conflict of interest: None declared Ethical approval: Not required