key: cord-256786-7gca01lr authors: Bartilotti‐Matos, F; Davies, P. title: Pearls and Pitfalls: two contrasting HIV diagnoses in the COVID‐19 era and the case for screening date: 2020-08-13 journal: J Med Virol DOI: 10.1002/jmv.26428 sha: doc_id: 256786 cord_uid: 7gca01lr The risk of coronavirus disease 2019 (COVID‐19) for people living with HIV (PLWH) is poorly understood. The vast majority of reported cases of COVID‐19/HIV co‐infection consists of those with an established HIV diagnosis who are on anti‐retroviral therapy (ART). Better knowledge of the effects of COVID19 on HIV patients who are ART naïve is required. Two cases of previously undiagnosed HIV presenting to secondary care with respiratory symptoms are detailed in this series, with a view to extrapolate lessons on blood borne virus (BBV) screening in the COVID‐19 era. This article is protected by copyright. All rights reserved. Two cases of previously undiagnosed HIV presenting to secondary care with respiratory symptoms are detailed in this series, with a view to extrapolate lessons on blood borne virus (BBV) screening in the COVID-19 era. The first patient, a fit and well white Scottish 38-year-old man, with a body mass index (BMI) of 24.6, presented after five days of dyspnoea and a productive cough. His temperature was 38 o C and SpO2 was 89% on room-air. Investigations were remarkable for a lymphocyte count of 0.7x10 9 /L, a c-reactive protein (CRP) of 242mg/L and a chest radiograph demonstrating subtle bibasal consolidation. Subsequently, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was present on polymerase chain reaction (PCR) from a viral swab. He rapidly deteriorated with progressive respiratory failure requiring intubation and ventilation. Whilst intubated, a routine BBV screen on day four of admission demonstrated HIV seropositivity. There were no discernible clinical or lifestyle risk factors for this diagnosis bar disease severity. At diagnosis, the viral load was 6.35log10 and CD4 + was 220cells/mm 3 . ART (emtricitabine/tenofovir and dolutegravir) and co-trimoxazole, for pneumocystis jiroveci pneumonia prophylaxis (PJP -PCR negative), were commenced via nasogastric tube. He went on to make a full recovery and was discharged on day 17 of admission. The second patient was a white Scottish 51-year-old man with a BMI of 23.6. He had a background of herpes zoster, weight loss, oral candidiasis and pernicious anaemia. He presented with dyspnoea and diarrhoea. Examination was unremarkable save oral candidiasis. He was afebrile, tachycardiac at 120bpm, mildly dyspnoeic at 23bpm and oxygen saturations were 96% on air. Bilateral consolidation on chest radiograph was reported as indeterminate Accepted Article for COVID-19. Blood investigations demonstrated a lymphocyte count of 0.4x10 9 , a CRP of 27mg/L and D-dimer of 720ng/mL. It was felt that COVID-19 was the likely diagnosis. A computed tomography pulmonary angiogram (CTPA) was performed, ruling out a pulmonary embolus but demonstrating bilateral ground glass changes that were reported as atypical for COVID-19. Despite these findings and two negative swabs for SARS-CoV2 PCR, COVID-19 remained the clinical diagnosis until day-six of admission when a BBV screen confirmed HIV seropositivity with a viral load of 5.28log10 and CD4 + 25cells/mm 3 . A subsequent sputum sample was positive for PJP on PCR for which he was started on treatment dose co-trimoxazole. He was started on ART (emtricitabine/tenofovir and raltegravir) prior to discharge. He was discharged on day 19 with follow-up by infectious diseases. The current scientific consensus is that PLWH receiving treatment are at no greater risk of severe COVID-19. 1, 2, 3, 4 However, the evidence base in the published literature pertains to stable patients with a supressed viral load. To the best of our knowledge only seven patients diagnosed with HIV at presentation with acute COVID-19 have been reported, see table one. 5, 6 There is an inference of a higher disease severity and younger age at presentation, however conventional risk factors such as obesity or respiratory disease impart significant variability. 15, 16 Case one is the first to our knowledge requiring intubation. These cases confer salient lessons. Firstly, the HIV and COVID-19 co-infection was diagnosed in the absence of risk factors, prompted by high disease severity in an atypically young and fit patient. On the second case, a classic presentation of PJP, a COVID-19 mimic, was initially missed in the context of the pandemic, due to similarities in clinical presentation, radiographic changes, and blood parameters. There are approximately 7,500 patients living with undiagnosed HIV in the UK. 7 They are considered immunosuppressed, under the assumption that this may correlate with a severe COVID-19 phenotype. 8 Previous case series have observed a non-significant correlation between a low CD4 + count and increased disease severity (table one), but this is inconsistent. 9 Without other risk factors for COVID-19, the severe presentation in case one supports this assertion. This also support previous findings of a lower age requiring hospitalisation. 2, 3, 8, 14 Larger studies in high prevalence settings are required to explore these associations further. The British HIV Association (BHIVA) recommends HIV screening for community acquired pneumonia presentations. 11 However, there is currently no extension of this to patients with COVID-19. A systematic review published in July 2020 states that HIV testing should be offered to anyone presenting with a clinical picture of viral pneumonia. 3 Active patient screening is required to extend our knowledge on the role of HIV as a risk factor for COVID-19. Undiagnosed PLWH represent a vulnerable patient group and advocating routine BBV screening is essential for those requiring hospitalisation with COVID-19. The additional benefit of this would be prompting the early diagnosis of mimics such as PJP, seen in the second case, which conveys a high mortality and requires aggressive treatment. Capacity in virology laboratories may preclude mass testing, however it should be advocated for in high-prevalence areas and in younger patients with atypically severe presentations. There may be a role for point of care HIV-antibody tests depending on local epidemiology and resources. There are no current or potential conflicts of interest. This article is protected by copyright. All rights reserved. Written informed consent was obtained for both patients. Francisca Bartilotti Matos and Peter Davies both conceived the idea of this correspondence and participated equally to its writing. We had full access to all the data in the study and had final responsibility to submit it for application. There have been no funding sources. None to declare. Table Table 1 -A summary of notable case series published to date of HIV/ COVID-19 co-infections. Basic demographics included country of origin and clinical characteristics of the cases. In addition to a precis of the main findings of the article. Clinical characteristics and outcomes in people living with HIV hospitalized for COVID-19 COVID-19 in people living with human immunodeficiency virus: a case series of 33 patients Coronavirus disease 2019 (COVID-19) outcomes in HIV/AIDS patients: a systematic review Clinical features and outcomes of HIV patients with coronavirus disease 2019 COVID-19 in patients with HIV: clinical case series Recovery from COVID-19 in two patients with coexisted HIV infection HIV in the United Kingdom: Towards Zero 2030: 2019 report Description of COVID-19 in HIV-infected individuals: a single-centre, prospective cohort Clinical features and outcome of HIV/SARS-CoV-2 coinfected patients in The Bronx Hospitalized Patients With COVID-19 and Human Immunodeficiency Virus: A Case Series UK National Guidelines for HIV Testing The Spanish HIV/COVID-19 Collaboration. Incidence and severity of COVID-19 in HIV positive persons receiving antiretroviral treatment A case of SARS-CoV-2 infection in an untreated HIV patient in Tokyo, Japan The characteristics of two patients coinfected with SARS-CoV-2 and HIV in Wuhan HIV/SARS-CoV-2 coinfected patients in Istanbul, Turkey COVID-19 in 3 people living with HIV in the United Kingdom One case of coronavirus disease 2019 (COVID-19) in a patient co-infected by HIV with a low CD4 + T-cell count