key: cord-1029055-f9gmlkez authors: Ruan, Lianguo; Zhang, Yan; Luo, Yanhe; Yu, Xiaoli; Zeng, Yan; Peng, Hong; Han, Lijun; Chen, Lan; Roy, Sankanika; Cheng, Qiguang; Li, Huan; Guo, Xianfeng; Xiong, Dexin; Gan, Hui; Liu, Mao title: Clinical features and outcomes of four HIV patients with COVID‐19 in Wuhan, China date: 2020-07-06 journal: J Med Virol DOI: 10.1002/jmv.26223 sha: 1379443c58733e7802d58a3ba76cd73a97b3c138 doc_id: 1029055 cord_uid: f9gmlkez SARS-CoV-2 is the coronavirus that has been identified as the pathogen causing COVID-19.1 Human Immunodeficiency Virus (HIV) attacks the immune system and leads to acquired immune deficiency syndrome (AIDS) in the late stage of disease. Concerns have been raised on HIV as a risk factor for COVID-19. This article is protected by copyright. All rights reserved. We described distinct clinical courses of COVID-19 in four patients with underlying HIV infection. Fever, cough, and dyspnea were common symptoms as those of large groups of patients. 3 It is to note that patient A had one time fever 3 days after transfer and 2 days of fever for the second time 2 weeks after transfer, and patient B had 3 days of fever 1 week after transfer. This might be explained by a protracted disease course complicated by AIDS-defining opportunistic infections (pneumocystis pneumonia for patient A and pharyngeal or esophageal infection for patient B). In addition, we could only assume that these two patients with severe form of COVID-19 were having significant clinical symptoms and high interleukin-6 level, due to which Tocilizumab was initiated. Overall, patients A and B, who were in the stage of AIDS, underwent a more complicated clinical course than patients C and D, who had asymptomatic HIV infection. 4 For patient A, chest CT performed around 3 weeks after symptom onset showed mainly diffuse bilateral predominantly involving perihilar and midzones with relative subpleural sparing (Figures 1(1A) and 1(1D) ), which were not typical radiological features of COVID-19. 5 Taken together, the history of intermittent fever and progressive respiratory symptoms refractory to supportive care, finding of pneumocystis jirovecii DNA in the sputum, response to HAART and antifungal medications, 6, 7 and the early stage radiological features favor an initial diagnosis of PCP rather than COVID-19. 8 Patients C and D had moderate clinical symptoms of COVID-19. Notably, patient C had multiple positive RT-PCR tests until around 6 weeks after symptom onset. In contrast, multiple RT-PCR tests for patient D were negative even 4 weeks after symptom onset, but only confirmed Envelope gene segment of SARS-CoV-2 in stool sample (test repeated) at 5 weeks. However, clinical data including close contact history with a confirmed COVID-19 case and the dynamic radiological features (Figure 1(3) ) that were in accordance with the published study 5 support a diagnosis of COVID-19. As to adaptive immune response, patients A and B who had CD4+ T-cell less than 50 cells/μL seemed to have insufficient or delayed immunoglobulin M (IgM) and/or IgG production. 9 Patient A had positive IgM and negative IgG 3 weeks after the initial positive RT-PCR result; however, IgM turned negative and IgG remained negative after another 3 weeks. By contrast, patient B has negative IgM and IgG twice more than 6 weeks after the initial positive RT-PCR result. Zhao et al 10 suggested that low CD4+ T-cell count might partly explain the early incomplete viral clearance and delayed humoral responses towards SARS-CoV-2. In summary, our paper highlights the importance of differential diagnoses for COVID-19 especially in patients with HIV infection based on dynamic clinical symptoms and radiological data. Large cohorts are required to further characterize the relationship between viral replication, immune response, and clinical progression of COVID-19, and to evaluate potential prophylactic and therapeutic options for patients with HIV infection. The proximal origin of SARS-CoV-2 Clinical features of patients infected with 2019 novel coronavirus in Wuhan Clinical characteristics of coronavirus disease 2019 in China ABC of AIDS: natural history and management of early HIV infection Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study Successful treatment of severe pneumocystis pneumonia in an immunosuppressed patient using caspofungin combined with clindamycin: a case report and literature review Efficacy of caspofungin combined with clindamycin for Pneumocystis jirovecii pneumonia in a systemic lupus erythematosus patient: a case report and literature review Pneumocystis jiroveci pneumonia: high-resolution CT findings in patients with and without HIV infection Antibody responses to SARS-CoV-2 in patients of novel coronavirus disease 2019 Early virus clearance and delayed antibody response in a case of COVID-19 with a history of co-infection with HIV-1 and HCV SUPPORTING INFORMATION Additional supporting information may be found online in the Supporting Information section The authors would like to thank Dingyu Zhang from Jinyintan Hospital and Long Cheng from Tongji Hospital for their coordination efforts. They would also like to thank Han Xiao from the Department of Virology, Erlangen-Nuremberg University, for his suggestive comments. The authors declare that there are no conflict of interests.