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      Co-infection with Coronavirus Disease 2019, previously undiagnosed Human Immunodeficiency Virus, Pneumocystis jirovecii pneumonia and Cytomegalovirus pneumonitis, with possible Immune Reconstitution Inflammatory Syndrome

      case-report

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          Abstract

          Background

          Case reports, case series and cohort studies have been published describing the clinical course and outcomes of people living with human immunodeficiency virus (PLWH) who contract coronavirus disease 2019 (COVID-19) pneumonia. However, the majority of the published work focuses on patients with well-controlled human immunodeficiency virus (HIV) on antiretroviral therapy (ART).

          Case presentation

          We present a case of a new diagnosis of HIV with Acquired Immune Deficiency Syndrome (AIDS) made simultaneously to diagnosis of COVID-19, with co-infection with pneumocystis jirovecii pneumonia (PJP) and possible cytomegalovirus (CMV) pneumonitis. The patient decompensated following initiation of ART, suggestive of possible immune reconstitution inflammatory syndrome (IRIS).

          Conclusions

          This case illustrates the importance of maintaining a high suspicion for HIV/AIDS in patients with risk factors. Additionally, this case raises the possibility that IRIS may develop in the setting of ART initiation in patients with COVID-19.

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          Most cited references15

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          Immune reconstitution inflammatory syndrome in patients starting antiretroviral therapy for HIV infection: a systematic review and meta-analysis.

          Monika Müller, Simon Wandel, Robert Colebunders … (2010)
          In patients with HIV-1 infection who are starting combination antiretroviral therapy (ART), the incidence of immune reconstitution inflammatory syndrome (IRIS) is not well defined. We did a meta-analysis to establish the incidence and lethality of the syndrome in patients with a range of previously diagnosed opportunistic infections, and examined the relation between occurrence and the degree of immunodeficiency. Systematic review identified 54 cohort studies of 13 103 patients starting ART, of whom 1699 developed IRIS. We calculated pooled cumulative incidences with 95% credibility intervals (CrI) by Bayesian methods and did a random-effects metaregression to analyse the relation between CD4 cell count and incidence of IRIS. In patients with previously diagnosed AIDS-defining illnesses, IRIS developed in 37.7% (95% CrI 26.6-49.4) of those with cytomegalovirus retinitis, 19.5% (6.7-44.8) of those with cryptococcal meningitis, 15.7% (9.7-24.5) of those with tuberculosis, 16.7% (2.3-50.7) of those with progressive multifocal leukoencephalopathy, and 6.4% (1.2-24.7) of those with Kaposi's sarcoma, and 12.2% (6.8-19.6) of those with herpes zoster. 16.1% (11.1-22.9) of unselected patients starting ART developed any type of IRIS. 4.5% (2.1-8.6) of patients with any type of IRIS died, 3.2% (0.7-9.2) of those with tuberculosis-associated IRIS died, and 20.8% (5.0-52.7) of those with cryptococcal meningitis died. Metaregression analyses showed that the risk of IRIS is associated with CD4 cell count at the start of ART, with a high risk in patients with fewer than 50 cells per microL. Occurrence of IRIS might therefore be reduced by initiation of ART before immunodeficiency becomes advanced. 2010 Elsevier Ltd. All rights reserved.
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            COVID-19 in Immunocompromised Hosts: What We Know So Far

            Monica Fung,, Jennifer M Babik (2020)
            Abstract The coronavirus disease 2019 (COVID-19) pandemic caused by SARS coronavirus 2 (SARS-CoV-2) has caused significant morbidity and mortality for patients and stressed healthcare systems worldwide. The clinical features and outcomes of COVID-19 among immunosuppressed patients, who are at presumed risk for more severe disease but who may also have decreased detrimental inflammatory responses, are not well characterized. We review the existing literature on COVID-19 among immunocompromised populations ranging from cancer patients and solid organ transplant recipients to patients with HIV and those receiving immunomodulatory therapy for autoimmune disease. Patients with malignancy and solid organ transplant recipients may be at increased risk of severe COVID-19 disease and death whereas for those with other types of immunocompromise, current evidence is less clear. Overall, further prospective, controlled studies are needed to determine the attributable risk of immunocompromising conditions and therapies on COVID-19 disease prognosis.
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              Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2016 Recommendations of the International Antiviral Society-USA Panel.

              Huldrych F. Günthard, Michael Saag, Constance A. Benson … (2016)
              New data and therapeutic options warrant updated recommendations for the use of antiretroviral drugs (ARVs) to treat or to prevent HIV infection in adults.
              Article 0 comments Cited 92 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): IDCases
                Journal ID (iso-abbrev): IDCases
                Title: IDCases
                Publisher: Published by Elsevier Ltd.
                ISSN (Electronic): 2214-2509
                Publication date PMC-release: 7 May 2021
                Publication date (Electronic): 7 May 2021
                Electronic Location Identifier: e01153
                Affiliations
                [a ]Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Suite GB, Boston, MA, 02215, USA
                [b ]Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
                [c ]Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, 3 Blackfan Circle, Boston, MA, 02115, USA
                Author notes
                [* ]Corresponding author.
                [1]

                Co-equal first authors.

                Article
                Publisher Item ID: S2214-2509(21)00109-8 Publisher ID: e01153
                DOI: 10.1016/j.idcr.2021.e01153
                PMC ID: 8103711
                PubMed ID: 33977081
                SO-VID: cd50c667-d806-455b-b6cd-3748054cd25a
                Copyright © © 2021 Published by Elsevier Ltd.
                License:

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                Date received : 2 March 2021
                Date revision received : 4 May 2021
                Date accepted : 4 May 2021
                Categories
                Subject: Case Report

                Keywords: covid-19,hiv,aids,pjp,iris
                Data availability:
                Keywords: covid-19, hiv, aids, pjp, iris

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