# Miliary TB and COVID-19 Coinfection in a Patient With a History of Post-polycythemia Vera Myelofibrosis Treated With Ruxolitinib: A Case Report

## TL;DR

A 70-year-old woman with a history of myelofibrosis treated with ruxolitinib developed miliary TB and COVID-19, highlighting the need for careful diagnosis in immunocompromised patients.

## Contribution

This case report highlights the complex interplay between ruxolitinib-induced immunosuppression, TB reactivation, and concurrent COVID-19 infection.

## Key findings

- The patient's TB was confirmed via bronchoscopy and PCR despite initial suspicion of COVID-19.
- Ruxolitinib use likely contributed to TB reactivation by impairing immune defenses.
- Symptomatic improvement occurred with standard antitubercular treatment.

## Abstract

The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted the diagnosis and management of tuberculosis (TB), a major public health issue. This case report discusses a 70-year-old female with post-polycythemia vera myelofibrosis (post-PV MF) treated with ruxolitinib who developed miliary TB amidst a COVID-19 infection. The patient presented with a flu-like syndrome over the past week with fatigue and weight loss the last month. When she was admitted to the hospital, the real-time polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was positive. Despite the typical COVID-19 presentation, her clinical and radiographic features raised suspicion for disseminated TB. Diagnostic tests, including bronchoscopy and PCR for Mycobacterium tuberculosis, confirmed miliary TB. She was treated with a standard antitubercular regimen, leading to symptomatic improvement. The interplay between COVID-19 and TB is complex, with COVID-19-induced immunosuppression, particularly lymphocytopenia, facilitating TB reactivation. Additionally, ruxolitinib, a Janus kinase (JAK) inhibitor used for myelofibrosis, impairs immune defense mechanisms, increasing infection risk, including TB. Prompt and accurate diagnosis of TB in the context of COVID-19 is crucial for effective management and improved patient outcomes. Clinicians should remain vigilant for TB reactivation in patients undergoing treatments such as ruxolitinib and consider alternative diagnoses despite positive SARS-CoV-2 tests. This report highlights the necessity for a comprehensive evaluation and timely intervention to mitigate the compounded risks of COVID-19 and TB.