key: cord-291577-nf80kih2 authors: Baluku, Joseph Baruch; Mwebaza, Shem; Ingabire, Gloria; Nsereko, Chris; Muwanga, Moses title: HIV and SARS‐CoV‐2 co‐infection: A case report from Uganda date: 2020-05-21 journal: J Med Virol DOI: 10.1002/jmv.26044 sha: doc_id: 291577 cord_uid: nf80kih2 There are no reports of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) and HIV co‐infection from sub‐Saharan Africa where 70% of people living with HIV are found. We report a case of HIV/SARS‐CoV‐2 co‐infection from Uganda. A 34 year old HIV‐positive female on antiretroviral therapy (tenofovir disoproxil fumarate, lamivudine and efavirenz) for 5 years, tested positive for SARS‐CoV‐2, the causative agent for coronavirus disease 19 (COVID‐19). She was asymptomatic at presentation but subsequently developed headache, chest pain, diarrhoea, anorexia and fatigue on day 3 of isolation without cough, fever or shortness of breath. Her CD4 count was 965 cells/mm(3), the HIV viral load was undetectable (<1,000 cells/mm(3)) and other laboratory work up was normal. She was successfully managed with hydroxychloroquine and broad spectrum antibiotics, and was discharged after 24 days. This case demonstrates an atypical clinical presentation of COVID – 19 in an HIV infected patient without other co‐morbidity. This article is protected by copyright. All rights reserved. laboratory work up was normal. She was successfully managed with hydroxychloroquine and broad spectrum antibiotics, and was discharged after 24 days. This case demonstrates an atypical clinical presentation of COVID - 19 in an HIV infected patient without other co-morbidity. Keywords: HIV, COVID-19, SARS-CoV-2, Uganda To the Editor, The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of the coronavirus disease 2019 (COVID- 19) , has been reported in over 3.6 million individuals worldwide including at least 35,000 people in Africa as of 7 th May 2020 (1) . Fever, cough, fatigue and shortness of breath are the predominant clinical manifestations of COVID-19, with the disease taking on a severe course in 25% of individuals (2) . Advanced age (>60 years) and having a chronic underlying condition have been reported to be associated with severe disease, lack of clinical improvement and mortality among patients with COVID -19 (3). Sub-Saharan Africa accounts for more than 70% of the global burden of HIV infection, and the co-infection with SARS-CoV-2 among HIV-infected patients is inevitable in this region, albeit with yet to be known clinical consequences (4) . There are few case reports on HIV/SARS-CoV-2 co-infection. From Wuhan, China, Zhu et al., reported a severe case of a newly diagnosed HIV/SARS-CoV-2 co-infected male with diabetes who presented with fever, hypoxemia, lymphopenia and chest computed tomography (CT) abnormalities, who was managed on oxygen therapy, the HIV antiviral agent lopinavir/ritonavir, moxifloxacin, gamma-globulin and methyl prednisone (5) . This article is protected by copyright. All rights reserved. Blanco et al. also reported 5 cases of HIV/SARS-CoV-2 co-infection -of whom 4 were virologically suppressed on antiretroviral therapy (ART) -from Spain, who invariably presented with cough and fever (6) . Two of these had other co-morbidities while one was newly diagnosed with advanced HIV (CD4 of 13 cells/mm 3 This article is protected by copyright. All rights reserved. There was no wasting, lymphadenopathy or pallor and her temperature was 36.4 degrees Celsius ( o C) (normal). She had a blood pressure of 110/80 millimetres of mercury (mmHg) and a pulse rate of 84 beats per minute (b/m), both of which were normal. The respiratory exam was significant for tachypnea (a respiratory rate of 26 breaths per minute (breaths/min)) with normal oxygen saturation (SPO 2 ) of 96% on ambient air. There was no respiratory distress, and auscultation of the chest was normal. On day 3, she CD4+ T-lymphocyte percentage measured on day 12 were 965 cells/mm 3 and 40.1% respectively. The HIV viral load performed (HIV-1 RT -PCR) on a dry blood spot was <1,000 copies/ml, that is, below the threshold of detection. The urine lipoarabinomannan, for tuberculosis, was negative. A repeat FBC on day 11 was normal. All symptoms had resolved by day 12. The respiratory rate was 16 b/min, the pulse rate was 80 beats/min, and she had a blood pressure of 126/88 mmHg. Throughout the admission period, her SPO 2 was >96% on ambient air and the This is the first case report of HIV/SARS-CoV-2 co-infection from sub-Saharan Africa. This case report highlights important clinical aspects of the co-infection. The patient did not have fever or cough, the two commonest symptoms of COVID -19 (8) . Rather, she developed gastrointestinal symptoms that occur in only 12% of patients with mild COVID -19 (9) . At the moment, it is unclear whether HIV-infected patients are likely to present with the less common symptoms of COVID -19 although "atypical" CT scan findings have been reported in an HIV-infected patient (10) . In a case series from Spain, all HIV/SARS-CoV-2 co-infected patients had cough and fever (6) . However, unlike the patient reported in this case report, they had other comorbid conditions, with one having concurrent Pneumocystis jiroveci pneumonia (PJP). One similarity to this case report is that 4 of the 5 patients This article is protected by copyright. All rights reserved. in the case series also presented with headache. Also, similar to this patient, the HIV co-infected patient who had good adherence to ART and a suppressed viral load, presented with weakness and non-bloody diarrhoea with no significant clinical signs and laboratory abnormalities in a case series from Turkey (11) The presentation with chest pain, tachypnea, normal auscultation findings and tachycardia raises the possibility of alternative diagnoses that could mimic COVID -19. Specifically, PJP and pulmonary embolism can present in a similar manner, and have been reported among patients with COVID -19 (6, 12) . In this patient, PJP was unlikely owing to an apparently normal CD4 count, normal oxygen saturation and the lack of fever. The lack of a CT scan at the treatment site precluded CT angiogram imaging to rule out pulmonary embolism. A chest X-ray was not performed for this patient either. However, its diagnostic accuracy for COVID -19, PJP and pulmonary embolism is low (13) . Elsewhere, imaging findings among HIV/SARS-CoV-2 co-infected findings include normal imaging findings, basal interstitial infiltrates, ground glass appearance and pleural effusion, all of which can occur with pulmonary embolism (6, 11, 14) . A high index of clinical suspicion for concurrent chest pathology due to other disease among HIV/SARS-CoV-2 co-infected is needed. This article is protected by copyright. All rights reserved. Save for the elevated ALP, the laboratory work up of this patient was unremarkable. The elevated ALP, a marker of bone resorption due to osteoblastic activity, is most likely caused by tenofovir rather than a unique feature of HIV/SARS-CoV-2 co-infection (15) . Optimal treatments for HIV/SARS-CoV-2 co-infection are unknown. The successful use of hydroxychloriquine, quinolones, and azithromycin has also been reported by other case reports (5, 6) . Larger studies are needed to evaluate the benefits and risks of hydroxychloroquine with or without antibiotics among HIV/SARS-CoV-2 co-infected. The optimal ART among HIV patients with COVID -19 is not established yet. This patient had been taking tenofovir, which has been showed to be effective against SARS-CoV-2 by binding RNA polymerase (16) . The EPICOS trial (NCT04334928) will This article is protected by copyright. All rights reserved. hopefully provide evidence for the role of co-administration of hydroxychloroquine with tenofovir. The benefit of lopinavir/ritonavir combination has been questioned among patients with severe COVID -19 (17) . The HIV/SARS-CoV-2 co-infected cases in literature took on a varied clinical course raging from mild to severe, although cure was realised in most of the cases (5, 6, 10, 11) . It is unclear whether HIV infection is protective against severe COVID -19 due to lack of a hyperactive immune response (18) . The patient presented herein had a normal CD4 count and seems to have experienced a moderate course of disease. Sensitive prognostic scores for low resource settings are needed to predict clinical course of COVID-19 among HIV patients (19) . In conclusion, HIV/SARS-CoV-2 co-infection is likely to become a common phenomenon in countries with a high HIV prevalence. There is need for larger prospective studies to characterise clinical manifestations of COVID -19 among HIV patients and determine optimal treatments, including appropriate ART regimens. Low resource settings need to build diagnostic capacity for COVID -19 "mimics" and prognostic biomarkers. World Health Organisation. 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Results from the International Cooperative Pulmonary Embolism Registry Tenofovir use is associated with an increase in serum alkaline phosphatase in the Swiss HIV Cohort Study Sofosbuvir, Galidesivir, and Tenofovir against SARS-CoV-2 RNA dependent RNA polymerase (RdRp): A molecular docking study A Trial of Lopinavir-Ritonavir in Adults Hospitalized with Severe Covid-19 Could HIV infection alter the clinical course of SARS-CoV-2 infection? When less is better COVID-19 Severity Scoring Tool for low resourced settings We acknowledge the clinical care team at Entebbe regional referral hospital for their dedication to the care of COVID -19 patients in Uganda. The authors declare no conflict of interest. None.This article is protected by copyright. All rights reserved.