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Clinical characteristics of COVID-19 and active tuberculosis co-infection in an Italian reference hospital To the Editor: Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan, China, in December 2019. In February 2020, an outbreak was detected in the Lombardy region of Italy, resulting in the first major outbreak outside Asia [1]. Tuberculosis (TB), the leading cause of death worldwide from a single infectious agent (1.5 million people per year) [2], like COVID-19, is mainly transmitted through the respiratory route and affects the lungs. Risk factors such as advanced age and some comorbidities, such as diabetes and chronic respiratory diseases, are associated with poor outcomes in both TB and COVID-19 [3]. However, only limited information about COVID-19 and active TB co-infection has been reported so far [4-6]. Concerns remain that COVID-19 could have a negative impact on the clinical course of TB and its ultimate outcome [7, 8]. This study describes clinical, radiological and laboratory characteristics of a series of COVID-19 patients with concurrent active TB in a hospital in Sondrio province, Lombardy region, in northern Italy. Patients with active TB admitted to the hospital were analysed to assess the impact of COVID-19 on their clinical course, as well as the radiological and laboratory consequences of the co-infection. TB diagnosis relied mainly on Xpert MTB/RIF and chest radiography (CXR) followed by culture confirmation and phenotypic and genotypic drug susceptibility testing (DST). At the time of TB diagnosis, patients were also tested for HIV. COVID-19 diagnosis was based on the results of real-time RT-PCR for SARS-CoV-2 from nasopharyngeal swabs. Radiological results at COVID-19 diagnosis were compared with the most recent radiographs available prior to the onset of COVID-19 to assess any change in pulmonary TB (PTB)-related lesions. A patient was considered COVID-19 laboratory-negative if two consecutive swabs, ⩾24 h apart, were negative. Follow-up swabs were performed after 14 days from diagnosis and then every 7 days until two consecutive swabs had a negative result [9]. Clinical data were recorded during a follow-up period of 6-41 days following the first positive swab. The study was approved by the ethics committee of Monza e Brianza (code 3377). Categorical variables are reported as absolute frequencies and percentages, while continuous variables are reported using median and interquartile range (IQR). Among the 24 in-patients diagnosed with active TB, we identified 20 cases with COVID-19 co-infection. Of those, 14 patients were referred from other hospitals in northern Italy and were admitted between 3 and 28 March 2020. On 25 March, a patient (P01), hospitalised in a single room since 14 March, underwent nasopharyngeal swab after reporting a documented COVID-19 case in the household. Since then, five patients (P02-06) with fever were tested and were positive. Subsequently, all the remaining patients were tested (P07...

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