key: cord-0835299-zu4ys0mn
authors: Alhoufie, Sari T.; Alsharif, Naif H.; Alfarouk, Khalid O.; Ibrahim, Nadier A.; Kheyami, Ali M.; Aljifri, Alanoud A.
title: COVID-19 with Underdiagnosed influenza B and parainfluenza-2 co-infections in Saudi Arabia: Two case reports
date: 2021-09-15
journal: J Infect Public Health
DOI: 10.1016/j.jiph.2021.09.005
sha: 4ce5666747b50ed04feb211ebe358dbe27395ea4
doc_id: 835299
cord_uid: zu4ys0mn

The emerging of the COVID-19 pandemic is currently challenging for the public health system globally. Beyond SARS-CoV-2 pathogenicity, co-infections with recycling respiratory pathogens, whether bacterial, viral, or fungal, might increase disease symptoms, morbidity, and mortality. In this study, we reported two COVID-19 cases in the early phase of the virus spread in Saudi Arabia with underdiagnosed respiratory viruses’ co-infections, influenza B and Parainfluenza-2, detected retrospectively. Fortunately, both patients recovered and were discharged home. Underestimation of co-infection among COVID19 patients might lead to hospital stay prolongation and increases morbidity and mortality. Therefore, it is crucial to consider and screen for co-infecting pathogens among COVID-19 patients and those with risk factors.

The association of viral respiratory tract infection and the rate of hospitalization, morbidity, and mortality is a significant concern in public health measurements and management. This concern is rising particularly with respiratory co-infection among those patients, which might increase the severity of the illness [1] .

Several studies reported respiratory pathogens during the current COVID-19 pandemic, including bacteria, viruses, and fungi, as co-infections among SARS-COV-2 patients [2, 3] . Early observation from Yang and his colleagues in China (Wuhan) found some SARS-CoV-2 patients with viral co-infections were in serious condition. Their treatments were more complicated and more prolonged in general [4] . Influenza viruses such as influenza A, B, and Parainfluenza seem to be commonly observed as viral co-infection agents among COVID-19 patients that show the clinical significance and increase the severity of the respiratory infection Acute Respiratory Distress Syndrome (ARDS) [5, 6] .

The first reported case of COVID-19 infection in Saudi Arabia was on Mar 2, 2021; since then, cases have exceeded 490,464 patients, including 470,328 recovered cases and 7,848 deaths as of Jul 3, 2021 [7] .

Unfortunately, few studies in Saudi Arabia were conducted to investigate co-infection incidences among COVID19 patients [8] [9] [10] .

This work reports two COVID-19 patients with underdiagnosed respiratory co-infecting viruses, which shed light on the importance of considering respiratory viral co-infections among COVID-19 in the current pandemic.

Two patients were admitted to Al-Madinah General Hospital, King Salman Medical city in Saudi Arabia, in the early phase of the COVID-19 pandemic during May and June 2020. Both patients were COVID-19 positive as their nasopharyngeal swabs were subjected to a reverse-transcription polymerase chain reaction (RT-PCR) at their admission time.

J o u r n a l P r e -p r o o f A 66-year-old female, diabetic type 2 on insulin, presented to the hospital on Jun 14, 2020, with fever (38°C), productive cough, chest pain, shortness of breath for six days, and partial pressure Oxygen was 88%. Chest x-ray showed bilateral coarse reticular shadow, and no pleural effusion occurred (figure 1a).

Other laboratory investigations showed positive C -reactive protein (CRP), International Normalized ratio (INR) of 1.04, blood glucose at the time of admission of 201, and Hb1AC was 6.4. Prothrombin time was 13.9 seconds (for other labs Investigations, see table 1). Treatment included Ceftriaxone 2 gm I.V. every 24 hours, Hydroxychloroquine 400 mg tablet oral for one day and then 200 mg orally every 12 hours for five days, Methylprednisolone 40mg/ml for two days, Enoxaparin 40 mg every 12 hours, Omeprazole 40 mg iv once per day, Paracetamol 1 gm oral tablet every 8 hours, Salbutamol nebulizer 2.5 mg every hour, and of Ipratropium bromide nebulizer 250 mg every 8 hours. Fortunately, after 12 days of hospital stays in a noncritical ward, the patient was discharged home.

A 44-year-old male patient with no comorbid diseases presented on May 14, 2020, with fever (37.5°C), productive cough for seven days, shortness of breath, and diarrhea for three days. Chest x-ray showed bilateral hilar bronchial wall thickening and no lung opacity (Figure 1b) , laboratory investigations showed positive C-reactive protein (for other lab investigations, see table 1). The patient was treated with Amoxicillin/Clavulanic acid 2 gm I.V. every hour for ten days, Azithromycin 500 mg for six days, Hydroxychloroquine, Paracetamol 1 gm, and Omeprazole 40 mg once daily. He was admitted to the isolation ward in the hospital and stayed 24 hours, then transferred to the hotel quarantine till his PCR test became negative, which was repeated ten days after infection diagnosis.

A nasopharyngeal swab from patients was sent to the Regional Lab, Health Affairs in Madinah and subjected to the cobas® 6800 SARS-CoV-2 RT-PCR test (Roche, Pleasanton CA, USA) using the fully automated cobas® 6800 (Roche Molecular Systems, Rotkeruz, Switzerland)). Target-specific primers were used to amplify the structural protein envelope E-gene and open reading frame (ORF) 1a of SARS-CoV-2.

J o u r n a l P r e -p r o o f Preserved Serum samples of the two patients were used to detect the IgM antibodies for influenza B and parainfluenza 2 in an indirect ELISA using Vircell IgM ELISA kits G/M1008 and G/M1010 respectively, (Vircell, Granada, Spain), according to the manufacturer's instructions.

All the patients' data were extracted from the patient's medical records. The Institutional Review Board approves this study of the General Directorate of Health Affairs in Madinah with the number (IRB 9-2021 ).

In this work, two patients infected with the COVID-19 virus in the early phase of the pandemic in Saudi Arabia (May and June 2020) showed retrospectively positive results for influenza B virus antibody IgM (case1) and Parainfluenza-2 antibody IgM (case2), indicating co-infections existence. Fortunately, the coinfection incidences did not lead to ARDS development or other complications, and patients were discharged home after 12 and 2 days of admission, respectively. On the other hand, the prolonged hospital stay is seen in case 1, which is attributed to the co-infection with influenza B and the patient co-morbidity (diabetes) and age (66 years).

The administered medications thoroughly covered most of the morbidity-related factors include:

-Many evidence suggested that thromboembolism becomes a recent cardinal of COVID-19 that worsens the disease prognosis and is associated with COVID-19-related-mortality [11] . Therefore, administration of Enoxaparin would represent a rational approach in reducing the disease relatedmorality [12, 13] .

-Cytokine storm, hyper-inflammation, lies within the core of COVID-19 and induced many factors that increase disease-related mortality [14] . Therefore, pharmacological agents that suppress this cytokine storm will eventually decrease the disease-related mortality, e.g., Acute Respiratory Distress Syndrome (ARDS) [15] . Methylprednisolone fitted to antagonize the cytokine storm, and so early administration of methylprednisolone will reduce the COVID-19-related morality [16, 17] -Although hydroxychloroquine is approved as an antiprotozoal drug, yet recently, it has been widely used off-label (re-purposing) in the management of rheumatoid arthritis and systemic lupus erythematosus due to its ability to stabilizes the lysosomal membrane [18, 19] ; thus, it prevents and/or decrease the releases of cathepsin enzymes, and so reduces the cytokine storm.

J o u r n a l P r e -p r o o f -Azithromycin is an example of macrolides antibiotics widely used to treat bacterial infections, especially atypical bacteria (bacteria that lack cell walls), as macrolides inhibit protein synthesis.

However, how does azithromycin affect the COVID-19 where its causation was viral and not a bacterial disease, which is a conundrum? One of the suggested explanations is that macrolides have antiinflmmatory properties, reducing hyper-inflammation [20] . Moreover, developing viral infection motly leads to developing secondary acute bacterial infection (SABI) [21] . Therefore, additional administration of ceftriaxone to cover the possible typical bacterial infection [22] .

Co-infections that occurred in these two cases were not diagnosed during the care time in the hospital.

Similar situations of misdiagnosing respiratory infecting pathogens during early (H1N1) pdm09 virus pandemic in Australia 2009 was reported [23] . However, few studies have reported viral co-infection during respiratory infection endemics such as MERS-COV and the current COVID-19 pandemic [2, 23, 24] .

This limitation in reporting is attributed to the underestimation of co-infection agents during the emergence of a novel pathogen of endemic or pandemic potential. Additionally, similar clinical manifestations, transmission route, and season time for COVID-19 and other circulating respiratory pathogens might encourage clinicians to exclude the possibility of co-infection existence [23, 25, 26 ].

An experimental study on cells culture and mice in China showed that the influenza virus facilitates SARS-CoV-2 infectivity via increasing the expression level of ACE2, which is the main target for the COVID19 virus to infect host cells [27] . Indeed, co-infection can seriously damage the immune system and accelerate the severity of the illness [4, 28, 29] . A study in Spain reported influenza A and B as co-infecting agents among SARS-COV-2 patients under mechanical ventilation [30] . A recent study in Saudi Arabia by Bander and colleagues found a positive correlation between co-infecting influenza H1N1 virus and mortality, particularly for ICU patients. Their study also detected several respiratory viruses among non-critical COVID-19 patients, such as influenza B, Parainfluenza-3, Adenovirus, and Metapneumovirus diagnosed via respiratory panel multiplex PCR [9] .

As the study is retrospective, some limitations are included. Besides the serological results, there were no available respiratory samples to conduct further confirmatory molecular diagnosis (PCR) for influenza B and Para-influenza viruses' infection. Furthermore, the patient's medical records did not notify if patients J o u r n a l P r e -p r o o f had previously received influenza vaccinations, which might minimize the severity of the current influenza co-infections. In addition, no follow-up been mentioned in patient's records since they have been discharged. However, the study highlighted the importance of considering possible underdiagnosed coinfections among COVID-19 patients and their challenging diagnosis in the clinical, radiographic, and laboratory investigations.

This report showed two COVID-19 patients with underdiagnosed co-infection respiratory pathogens, influenza B and Parainfluenza-2. Thus, screening for possible co-pathogens among COVID-19 patients, particularly respiratory virus, is essential to handle their effect that might lead to ARDS and other complications during the current COVID-19 pandemic.

Implementation of a wide range of diagnostic tests such as respiratory panel multiplex PCR and simple antibodies detection techniques (ELISA, latex, etc.) for these co-pathogens in hospital and regional labs would minimize the possibility of misdiagnosing the incidences of COVID-19 co-infections. A further prospective cohort study to investigate the prevalence of influenza viruses among COVID-19 patients is in progress.

The authors declare that they have no known competing financial interests that could have influenced the work reported in this paper.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Tables: 

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We thank Mr. Khaled Aljabri, and Mr. Adnan Khoumaeys for their help. Our thanks also extended to the Academic Affairs in King Salman Medical City in Madinah for their support.