Introduction: Tuberculosis (TB) remains a major public health challenge despite being a preventable and curable infectious disease. Early diagnosis and access to treatment are essential to tackle its transmission and mortality. The COVID-19 pandemic led to worldwide healthcare service disruptions and an underrecognized impact on the global fight against TB. Objective: To describe the clinical and epidemiological characteristics of TB patients diagnosed during the COVID-19 pandemic period. Methods: We conducted a retrospective observational study at a tertiary hospital center in Porto, Portugal, reviewing all patients admitted and diagnosed with TB between January 2020 and December 2022. Demographic data, clinical manifestations, immunosuppression status, microbiological and radiological findings, treatment and outcomes were analysed. Results: A total of 72 patients were diagnosed with TB during the study period. Most were male with a median age of 54 years. More than one-third were immunosuppressed. The median interval from symptom onset to diagnosis was 60 days. Pulmonary TB with sputum-smear positivity and cavitary lesions accounted for the majority of cases. Treatment was initiated in all but one patient. Overall, most patients (88.9%) achieved successful outcomes. Conclusion: During the COVID-19 pandemic, significant delays in TB diagnosis led to a substantial proportion of patients presenting with advanced pulmonary disease. These findings underscore the constraints felt during an unprecedented health crisis and the need for resilient TB programs capable of maintaining diagnostic and treatment services. Further research is warranted to quantify the long-term effects of the pandemic on TB control efforts.
References
[1]
Hershkovitz, I., Donoghue, H.D., Minnikin, D.E., May, H., Lee, O.Y.-C., Feldman, M., et al. (2015) Tuberculosis Origin: The Neolithic Scenario. Tuberculosis, 95, S122-S126. https://doi.org/10.1016/j.tube.2015.02.021
[2]
Nicklisch, N., Maixner, F., Ganslmeier, R., Friederich, S., Dresely, V., Meller, H., et al. (2012) Rib Lesions in Skeletons from Early Neolithic Sites in Central Germany: On the Trail of Tuberculosis at the Onset of Agriculture. American Journal of Physical Anthropology, 149, 391-404. https://doi.org/10.1002/ajpa.22137
[3]
Gutierrez, M.C., Brisse, S., Brosch, R., Fabre, M., Omaïs, B., Marmiesse, M., et al. (2005) Ancient Origin and Gene Mosaicism of the Progenitor of Mycobacterium tuberculosis. PLOS Pathogens, 1, e5. https://doi.org/10.1371/journal.ppat.0010005
[4]
Donoghue, H.D. (2009) Human Tuberculosis—An Ancient Disease, as Elucidated by Ancient Microbial Biomolecules. Microbes and Infection, 11, 1156-1162. https://doi.org/10.1016/j.micinf.2009.08.008
[5]
Raviglione, M. and Sulis, G. (2016) Tuberculosis 2015: Burden, Challenges and Strategy for Control and Elimination. Infectious Disease Reports, 8, Article 6570. https://doi.org/10.4081/idr.2016.6570
[6]
Houben, R.M.G.J. and Dodd, P.J. (2016) The Global Burden of Latent Tuberculosis Infection: A Re-Estimation Using Mathematical Modelling. PLOS Medicine, 13, e1002152. https://doi.org/10.1371/journal.pmed.1002152
[7]
Menzies, N.A., Wolf, E., Connors, D., Bellerose, M., Sbarra, A.N., Cohen, T., et al. (2018) Progression from Latent Infection to Active Disease in Dynamic Tuberculosis Transmission Models: A Systematic Review of the Validity of Modelling Assumptions. The Lancet Infectious Diseases, 18, e228-e238. https://doi.org/10.1016/s1473-3099(18)30134-8
[8]
Alsayed, S.S.R. and Gunosewoyo, H. (2023) Tuberculosis: Pathogenesis, Current Treatment Regimens and New Drug Targets. International Journal of Molecular Sciences, 24, Article 5202. https://doi.org/10.3390/ijms24065202
[9]
Bagcchi, S. (2023) Who’s Global Tuberculosis Report 2022. The Lancet Microbe, 4, E20. https://doi.org/10.1016/s2666-5247(22)00359-7
[10]
Small, P.M. and Fujiwara, P.I. (2001) Management of Tuberculosis in the United States. New England Journal of Medicine, 345, 189-200. https://doi.org/10.1056/nejm200107193450307
[11]
Suárez, I., Fünger, S.M., Kröger, S., Rademacher, J., Fätkenheuer, G. and Rybniker, J. (2019) The Diagnosis and Treatment of Tuberculosis. Deutsches Ärzteblatt international, 116, 729-735. https://doi.org/10.3238/arztebl.2019.0729
[12]
Tiemersma, E.W., van der Werf, M.J., Borgdorff, M.W., Williams, B.G. and Nagelkerke, N.J.D. (2011) Natural History of Tuberculosis: Duration and Fatality of Untreated Pulmonary Tuberculosis in HIV Negative Patients: A Systematic Review. PLOS ONE, 6, e17601. https://doi.org/10.1371/journal.pone.0017601
[13]
Uplekar, M. and Raviglione, M. (2015) Who’s End TB Strategy: From Stopping to Ending the Global TB Epidemic. Indian Journal of Tuberculosis, 62, 196-199. https://doi.org/10.1016/j.ijtb.2015.11.001
[14]
Dheda, K., Perumal, T., Moultrie, H., Perumal, R., Esmail, A., Scott, A.J., et al. (2022) The Intersecting Pandemics of Tuberculosis and COVID-19: Population-Level and Patient-Level Impact, Clinical Presentation, and Corrective Interventions. The Lancet Respiratory Medicine, 10, 603-622. https://doi.org/10.1016/s2213-2600(22)00092-3
[15]
Falzon, D., Zignol, M., Bastard, M., Floyd, K. and Kasaeva, T. (2023) The Impact of the COVID-19 Pandemic on the Global Tuberculosis Epidemic. Frontiers in Immunology, 14, Article 1234785. https://doi.org/10.3389/fimmu.2023.1234785
[16]
Ledesma, J.R., Basting, A., Church, H.T., Ma, J., Zhang, M., Vongpradith, A., et al. (2023) Global-, Regional-, and National-Level Impacts of the COVID-19 Pandemic on Tuberculosis Diagnoses 2020-2021. Microorganisms, 11, Article 2191. https://doi.org/10.3390/microorganisms11092191
[17]
Nalunjogi, J., Mucching-Toscano, S., Sibomana, J.P., Centis, R., D’Ambrosio, L., Alffenaar, J., et al. (2023) Impact of COVID-19 on Diagnosis of Tuberculosis, Multidrug-Resistant Tuberculosis, and on Mortality in 11 Countries in Europe, Northern America, and Australia. a Global Tuberculosis Network Study. International Journal of Infectious Diseases, 130, S25-S29. https://doi.org/10.1016/j.ijid.2023.02.025
[18]
Khachatryan, N., Atshemyan, H., Manukyan, A., Khachatryan, A. and Poghosyan, K. (2022) The Impact of Covid-19 Pandemic on the Detection of Tuberculosis in Armenia. Journal of Tuberculosis Research, 10, 199-204. https://doi.org/10.4236/jtr.2022.104015
[19]
World Health Organization (2021) WHO Guidelines Approved by the Guidelines Review Committee, in WHO Consolidated Guidelines on Tuberculosis: Module 3: Diagnosis-Rapid Diagnostics for Tuberculosis Detection.
[20]
Imtiaz, S., Shield, K.D., Roerecke, M., Samokhvalov, A.V., Lönnroth, K. and Rehm, J. (2017) Alcohol Consumption as a Risk Factor for Tuberculosis: Meta-Analyses and Burden of Disease. European Respiratory Journal, 50, Article 1700216. https://doi.org/10.1183/13993003.00216-2017
[21]
Davies, P.D.O., Yew, W.W., Ganguly, D., Davidow, A.L., Reichman, L.B., Dheda, K., et al. (2006) Smoking and Tuberculosis: The Epidemiological Association and Immunopathogenesis. Transactions of the Royal Society of Tropical Medicine and Hygiene, 100, 291-298. https://doi.org/10.1016/j.trstmh.2005.06.034
[22]
Couceiro, L., Santana, P. and Nunes, C. (2011) Pulmonary Tuberculosis and Risk Factors in Portugal: A Spatial Analysis. The International Journal of Tuberculosis and Lung Disease, 15, 1445-1455. https://doi.org/10.5588/ijtld.10.0302
[23]
Lawn, S.D. and Zumla, A.I. (2011) Tuberculosis. The Lancet, 378, 57-72. https://doi.org/10.1016/s0140-6736(10)62173-3
[24]
de Perio, M.A., Kobayashi, M. and Wortham, J.M. (2020) Occupational Respiratory Infections. Clinics in Chest Medicine, 41, 739-751. https://doi.org/10.1016/j.ccm.2020.08.003
[25]
Kassaw, A., Kefale, D., Aytenew, T.M., Azmeraw, M., Agimas, M.C., Zeleke, S., et al. (2024) Burden of Mortality and Its Predictors among TB-HIV Co-Infected Patients in Ethiopia: Systematic Review and Meta-Analysis. PLOS ONE, 19, e0312698. https://doi.org/10.1371/journal.pone.0312698
[26]
Bhargava, A. and Shewade, H.D. (2020) The Potential Impact of the COVID-19 Response Related Lockdown on TB Incidence and Mortality in India. Indian Journal of Tuberculosis, 67, S139-S146. https://doi.org/10.1016/j.ijtb.2020.07.004
[27]
Narita, M., Hatt, G., Gardner Toren, K., Vuong, K., Pecha, M., Jereb, J.A., et al. (2021) Delayed Tuberculosis Diagnoses during the Coronavirus Disease 2019 (COVID-19) Pandemic in 2020—King County, Washington. Clinical Infectious Diseases, 73, S74-S76. https://doi.org/10.1093/cid/ciab387
[28]
Min, J., Ko, Y., Kim, H.W., Koo, H., Oh, J.Y., Jeong, Y., et al. (2022) Increased Healthcare Delays in Tuberculosis Patients during the First Wave of COVID-19 Pandemic in Korea: A Nationwide Cross-Sectional Study. Journal of Korean Medical Science, 37, e20. https://doi.org/10.3346/jkms.2022.37.e20
Wang, Q., Cao, Y., Liu, X., Fu, Y., Zhang, J., Zhang, Y., et al. (2024) Systematic Review and Meta-Analysis of Tuberculosis and COVID-19 Co-Infection: Prevalence, Fatality, and Treatment Considerations. PLOS Neglected Tropical Diseases, 18, e0012136. https://doi.org/10.1371/journal.pntd.0012136
[31]
The TB/COVID-19 Global Study Group (2022) Tuberculosis and COVID-19 Co-Infection: Description of the Global Cohort. European Respiratory Journal, 59, Article 2102538. https://doi.org/10.1183/13993003.02538-2021
[32]
Di Bari, V., Cerva, C., Libertone, R., Carli, S.M., Musso, M., Goletti, D., et al. (2025) Impact of Severity of COVID-19 in TB Disease Patients: Experience from an Italian Infectious Disease Referral Hospital. Infectious Disease Reports, 17, Article 11. https://doi.org/10.3390/idr17010011
[33]
Gupta, N., Ish, P., Gupta, A., Malhotra, N., Caminero, J.A., Singla, R., et al. (2020) A Profile of a Retrospective Cohort of 22 Patients with COVID-19 and Active/Treated Tuberculosis. European Respiratory Journal, 56, Article 2003408. https://doi.org/10.1183/13993003.03408-2020
[34]
Mihuta, C., Socaci, A., Hogea, P., Tudorache, E., Mihuta, M.S. and Oancea, C. (2025) Comparative Insights into COVID-19 and Tuberculosis: Clinical Manifestations, Inflammatory Markers, and Outcomes in Pulmonary versus Extrapulmonary Tuberculosis and SARS-CoV-2 Co-Infection. Journal of Clinical Medicine, 14, Article 2782. https://doi.org/10.3390/jcm14082782
