CRITICAL DEGREE OF COVID-19
PNEUMONIA AN A MAN WITH HIV
Tenno Ukaga, Isa Ansori
Universitas Lambung Mangkurat, Indonesia
Email: [email protected], [email protected]
|
KEYWORDS Covid-19, HIV/AIDS, CT Value. |
ABSTRACT Severe
acute respiratory syndrome corona virus-2 (SARS-CoV-2), appeared in the city
of Wuhan, China. SARS-CoV-2 causes the Coronavirus disease 2019 (COVID-19),
which has resulted in the most devastating pandemic in modern world history.
Epidemiological data show that COVID-19 infection with a poor prognosis
occurs in the general population with chronic systemic immune deficiency and
inflammatory conditions in patients. People with HIV/AIDS (ODHA) have a
higher risk of being infected with COVID-19. Research related to COVID-19
infection in HIV/AIDS patients still yields different results in terms of
susceptibility to infection, clinical characteristics, severity of symptoms,
and prognosis. It is aimed that this case will
provide an up-to-date picture of the incidence of COVID-19 in HIV cases The method used in this study is qualitative
and a case study of shortness of breath patients. Clinical
characteristics of COVID-19 patients and age range 26-82 years. In
hospitalized patients, the appropriate treatment strategy depends on the
severity of the disease. Treatment for COVID-19 patients with HIV
co-infection is the same as for COVID-19 without HIV infection.
Immunosuppression in COVID-19 can delay viral clearance and prolong the course
of the disease. Monitoring viral load and CD4 count are variables that
influence the severity of symptoms. Critical
degree Covid 19 patients with HIV have a poor prognosis, but with adequate
management the patient experiences clinical improvement and can go home for
independent isolation. |
INTRODUCTION
In
December 2019, a new corona virus, severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2), appeared in the city of Wuhan, China. SARS-CoV-2
causes the coronavirus disease 2019 (COVID-19), which has resulted in the most
devastating pandemic in modern world history. The clinical presentation of
COVID-19 patients can be asymptomatic or consist of mild symptoms, from cough
and fever to severe and life-threatening acute respiratory syndrome (ARDS),
sepsis, multi-organ failure and death. There is no specific treatment currently
for COVID-19 but organ function support needs to be provided when symptoms are
severe, and severe cases require admission to hospital for supportive clinical
management such as mechanical ventilation (Cooper et al., 2020; Zaim et al., 2020).
Several
studies have shown that increasing age, hypertension and diabetes are risk
factors that correlate with poorer clinical outcomes. Until now, little is
known whether people living with HIV (PLWHA) are at greater risk than the
general population. If left untreated, HIV infection results in a reduced
number of CD4 T cells, leading to AIDS. AIDS was defined as a CD4 T-cell count
<200 cells/μL or the presence of a disease that defines AIDS. In 2018, an
estimated 37.9 million people worldwide had HIV infection, 23.3 million of whom
were currently being treated with antiretroviral therapy (ART) (Jordan et al., 2020; Siedner & Triant, 2019; Vishnevetsky & Levy,
2020; Zheng et al., 2020). Eighty-six
percent of those on treatment had successful viral suppression, resulting in
undetectable viral loads and non-transmissible disease. If ART is maintained
and adhered to, people living with HIV are not in an immunocompromised
condition. Nonetheless, PLWHA may be at risk of developing severe COVID-19,
especially in areas where HIV infection is not well controlled. Research is
limited regarding the impact of HIV on SARS-CoV-2 infection and whether it has
any effect on the clinical outcome of COVID-19 (Cooper et al., 2020; Joob, 2020; Rodger et al., 2019).
In this
case report, a case of a 39-year-old male patient with Pneumonia COVID-19
HIV/AIDS will be presented. It is aimed that this
case will provide an up-to-date picture of the incidence of COVID-19 in HIV
cases.
RESEARCH METHOD
The study used case study method.
Moreover, the case is: a
39-year-old man complained of shortness of breath, cough and fever in the last
seven days. The Sars Cov PCR examination showed a positive result with a ct
value of 11.64. With a positive rapid HIV test with CD4 74 results. The patient
also experienced increased levels of liver enzymes (SGOT 357, SGPT 346), LDH
1394, CRP 74.9, D-dimer 2.78, hyponatremia (Na 126), and decreased P/F values
Ratio 107. Chest X-ray showed bilateral pneumonia. The patient received
antiviral therapy with remdesivir for 10 days, levolfoxacin and ceftrikson
antibiotics, prophylaxis for opportunistic infections (cotrimoxazole 960 mg)
steroid metylprednisolone and fondaparinux for 5 days. The patient received ARV
after 15 days of treatment. During the treatment period the patient experienced
clinical improvement, decreased inflammatory markers, increased p/f ratio,
increasing CT values and improving thoracic radiology. The patient was
treated as an outpatient after being treated for 30 days.
RESULT AND DISCUSSION
Case
Mr. RN, 39
years old, ethnic Banjar, Muslim, self-employed, comes from Kotabaru district,
South Kalimantan. Entered the Ulin Banjarmasin Regional General Hospital (RSUD)
since August 13, 2022.
Disease
History
Present medical history
The
patient came with shortness of breath since 7 days before entering the
hospital. Shortness of breath 3 days before admission to the hospital.
Shortness of breath is not affected by position or activity. The patient also
complained of fever since 7 days before entering the hospital, fever fluctuated
with coughing up phlegm. Phlegm is white. Coughing up blood and chest pain was
denied by the patient. The patient also complained of nausea and vomiting and
decreased appetite. BAK and CHAPTER normal. Anosmia and ageusia are denied.
Past medical history
The
patient had no history of diabetes mellitus, hypertension or bronchial asthma.
Previous history of HIV is still unknown. History of changing sexual partners
was denied. The patient has a history of diarrhea for almost one month. The
complaint of thrush was denied. BB dropped dramatically in 1 month but did not
weigh.
Social and Family History
The patient works as an
entrepreneur. History of frequent change of sex partners was denied. The
patient was not aware of any previous history of HIV. History of alcohol and
drug use was denied. There is no family history of high blood pressure,
diabetes and asthma.
Based on
the data above, the list of fixed problems is; (1) Covid 19 critical degree,
(2) CAP Severe, (3) HIV Stad II, (4) Normochromic normocytic anemia, (5)
Transaminitis, and (6) Hyponatremia
Problem Analysis and Treatment Plan
Based on the list
of fixed problems, a problem analysis is made as follows:
Table 1. Problem
Analysis and Treatment Plan
|
Problem
List |
Diagnostic
Plan |
Therapy
Plan |
Monitoring
Plan |
|
|
1. |
Covid
19 degrees critical |
- |
02
NRM 15 LPM Ivfd
Asering 800cc/24 hours Remdesivir
drip 1x200 mg (h1) then 1x100 Drip
resfar 25cc/24 hours Drip
vitamin c 2x500 mg Inj.
Methylprednisolone 2x31.25 Inj
omeprazole 1x40 inj.
Arixtra 1x2,5 POs: Vitamin
D 1x5000 l-bio
2x1 zinc
1x20 |
Clinical Signs
of bleeding, PT/APTT, D-Dimer AGD/clinical vital
signs O2
Saturation, |
|
2. |
Severe
CAP |
Sputum
gram, K/S sputum |
Inj
Ceftriaxone 3x2 gr Inj
Levofloxacin 1x750 mg |
Clinical DLO
after 3 days AB vital
signs O2
saturation |
|
3. |
HIV
Stage II |
Anti-HIV
Elisa CD4 Consul
IPD tropical infections |
Cotrimoxazole
1x960 mg PO |
TTV,
clinical CD4 |
|
4. |
Anemia |
Peripheral
blood smear examination |
- |
K/TTV,
Hb examination |
|
5. |
Transaminitis |
Abdominal
ultrasound Gastrohepatology
IPD consultation |
Hepatoprotector
3x1 caps PO |
Clinical vital
signs SGOT/SGPT
, bilirubin per 3 days |
|
6. |
Hyponatremia |
Urine
electrolytes |
IVFD
NS 500 cc/24 hours |
K/TTV,
post-correction SE examination |
Table 2. Notes on
the progress and course of the patient's disease
|
13-15 August 2022 |
August 16-19, 2022 |
August 20-27, 2022 |
September 2-13, 2022 |
|
|
|
1.
Covid 19 degrees critical 2.
CAP Severe 3.
HIV Stage II 4.
Normochromic normocytic anemia 5.
Transaminitis 6.
Hyponatremia |
1.Covid
19 degrees critical 2. CAP
Severe 3. HIV
Stage II 4.Normochromic
normocytic anemia 5.
Transaminitis 6.
Hyponatremia 7.
hypoalbumin |
1.Covid
19 degrees critical 2. CAP
Severe Improvements 3. HIV
Stage II 4.Normochromic
normocytic anemia 5.
Transaminitis 6. Hyponatremia 7.
hypoalbumin 8.
constipation 9.
Stomatitis |
1.Covid
19 degrees critical 2. CAP
Severe Improvements 3. HIV
Stage II 4.Normochromic
normocytic anemia 5.
Transaminitis 6.
Hyponatremia 7.
hypoalbumin 8.
constipation 9.
Stomatitis |
|
Monitoring |
Clinical,
vital signs |
Clinical,
vital signs |
Clinical,
vital signs |
Clinical,
vital signs |
|
PlanningDiagnosis |
Clinical Signs of
bleeding, PT/APTT, D-Dimer AGD/clinical vital
signs O2
Saturation, |
Clinical Signs of
bleeding, PT/APTT, D-Dimer AGD/clinical vital
signs O2
Saturation, |
Clinical Signs of
bleeding, PT/APTT, D-Dimer AGD/clinical vital
signs O2
Saturation, |
Clinical Signs of
bleeding, PT/APTT, D-Dimer AGD/clinical vital
signs O2
Saturation, |
|
Consul's reply |
||||
|
Anesthesia(4/10/2021) |
|
|
|
|
|
In principle agreed to be treated in the
ICU Covid room |
|
|
|
|
Discussion
Coronavirus
disease (COVID)-19 is a condition of severe acute respiratory syndrome (SARS)
caused by infection with the SARS-COV-2 virus which has now become a pandemic
worldwide. Based on epidemiological data, patients who have comorbid diseases
such as diabetes mellitus (DM), chronic kidney disease, hypertension, heart
disease, and chronic lung disease are more susceptible to COVID-19 infection
with a worse prognosis than the general population due to chronic systemic
immune deficiency. and inflammatory conditions in patients. Other immune
deficiency conditions such as people with HIV/AIDS (PLWHA) are also considered
to have a higher risk of being infected with COVID-19 with a worse prognosis (C. Huang et al., 2020; WHO, nd; Widiasari et al.,
2020). Research
related to COVID-19 infection in HIV/AIDS patients still yields different
results in terms of susceptibility to infection, clinical characteristics,
severity of symptoms, and prognosis (Widiasari et al., 2020). In this case
report, a man with HIV/AIDS suffers from COVID-19.
The
patient came with a diagnosis of Critical Covid-19, Severe CAP, Stage II HIV,
Transaminitis, Hypochromic Microcytic Anemia, and Hyponatremia. The patient
received Resfar drip therapy 25cc/24 hours, Vitamin C drip 2x500 mg, Remdesivir
drip 1x200 mg (H1) continued 1x100 mg, Inj. Ceftriaxone 2x1 gram, Inj.
Levofloxacin 1x750mg, Inj. Arixtra 1x2.5, Cotrimoxazol 1x960 mg, Vit D 1x5000
iu, Lbio 2x1 sac, Zinc 1x20mg, O2 NRM, Diet TKTP 1700 kcal, IVFD aser 1500
ml/24 hours, Omeprazole 1x40 mg, PCT 3x1 gk/p fever, HP pro 3x1 and CPG 1x75
mg.
In
patients with severe or critical Covid-19 degrees, based on the Covid-19
Edition 4 Patient guidelines, namely isolation in the isolation room of the
Intensive Care Unit (ICU) or High Care Unit (HCU) of a Referral Hospital.
COVID-19 intensive care. It is very important for earlier and complete
intervention for critically ill patients with COVID-19. Patients need complete
rest, adequate caloric intake, electrolyte control, hydration status (fluid
therapy), and oxygen. Complete peripheral blood laboratory monitoring with type
count, if possible add CRP, kidney function, liver function, Hemostasis, LDH,
D-dimer. Examination of serial chest X-ray if worsening. Monitor clinical signs
such as tachypnea, respiratory rate ≥ 30x/min, oxygen saturation with pulse
oximetry ≤93% (on the finger), - PaO2/FiO2 ≤ 300 mmHg, increase by > >50%
in lung area involvement on chest imaging within 24-48 hours, progressive
lymphopenia, progressively elevated CRP and progressive lactic acidosis (Burhan, 2020).
Initiate
oxygen therapy if SpO2 is found to be 94%. Increase oxygen therapy using an
HFNC (High Flow Nasal Cannula) device if there is no clinical improvement. 0.9%
NaCl was also given intravenously (IV) drip during treatment. Pharmacology such
as Vitamin B1 1 ampoule/24 hours/intravenously, Vitamin D Dosage of 1000-5000
IU/day (available in the form of 1000 IU tablets and 5000 IU chewable tablets).
If there is a condition of sepsis that is strongly suspected due to bacterial
co-infection, the selection of antibiotics is adjusted to the clinical
condition, the focus of infection and the risk factors present in the patient.
Blood cultures should be performed and sputum culture examination (with special
caution) should be considered. Antiviral Remdesivir 200 mg IV drip (day 1)
followed by 1x100 mg IV drip (day 2-5 or day 2-10) (Burhan, 2020).
Remdesivir
is a nucleotide analog prodrug. This drug binds to RNA-dependent RNA polymerase
and inhibits viral replication by terminating RNA transcription (Cooper et al., 2020). Remdesivir will
enter the epithelium of the respiratory tract and will be metabolized in host
cells into an active nucleoside triphosphate. This drug can inhibit
RNA-dependent RNA polymerase through competition with adenosine triphosphate.
In addition, nucleoside analogues can also enter the generating RNA strand and
cause the viral replication process to be delayed (Yousaf et al., 2021). In in vitro
tests, it was found that remdesivir had antiviral activity against SARS-CoV-2
in human airway epithelial cultures. The half maximal effective concentration
(EC50) of this drug is 0.01 M (Siedner & Triant, 2019). Remdesivir is
administered intravenously and is available as a lyophilized solution and/or
powder to be administered as an infusion over 30-120 minutes. The Food and Drug
Administration (FDA) allows the administration of remdesivir as a COVID-19 therapy
for adults and children aged ≥ 28 days and weighing ≥ 3 kg. In hospitalized
patients, remdesivir is given for 5 days or until the patient is discharged
(choose the shorter duration). Whereas in patients who are not treated, but are
at high risk of severe symptoms, remdesivir should be given within the first 7
days of symptom onset for 3 days. The recommended dosing regimen is a single
dose of 200 mg on the first day, followed by 100 mg once a day in the following
days (the duration of treatment is not more than 10 days) (Vishnevetsky & Levy, 2020). The use of
remdesivir in special populations such as pregnant women, can be given if the
benefits outweigh the risks to the mother and fetus. For patients with
end-stage renal disease (ESRD), its safety has not been established, but its
use is not recommended in adults and children with an eGFR less than 30 ml/min.
The use of remdesivir in patients with hepatic impairment is permitted if the
potential risk is considered to be small (Jordan et al., 2020). Remdesivir can
interact with rifampicin, carbamazepine and phenytoin so it should not be given
simultaneously (Rodger et al., 2019).
In
critically ill COVID-19 patients, sepsis is often suspected due to bacterial
co-infection. Consideration of giving antibiotics based on clinical conditions,
focus of infection, and patient risk factors. A blood culture should be
obtained and a sputum culture may also be considered (Joob, 2020). A study by
Mustafa et al., described that there was a 100% increase in the use of
antibiotics in patients treated in the ICU. The use of antibiotics in
outpatients is as much as 25%, while in patients admitted to the hospital it
increases to 90%. For patients admitted to the ICU, antibiotics were
administered to all patients (Widiasari et al., 2020). Similar use of
antibiotics was also found in another study by Miranda et al., This was
associated with severe clinical manifestations in patients as well as
laboratory markers indicating ongoing active inflammation (Widiasari et al., 2020).
In
COVID-19 patients, especially those with severe or critical degrees, it will be
difficult to distinguish whether the worsening is due to co-infection or a
manifestation of a cytokine storm. Markers such as procalcitonin cannot be used
solely to determine the administration or delay of antibiotics. Therefore,
currently, antibiotics should be administered to patients with a high suspicion
of bacterial co-infection. In addition to COVID-19 patients who are
immunocompromised, antibiotics can be given before other supporting results are
available because of the possibility of rapid deterioration if these patients
experience bacterial co-infection. Immunocompromised itself includes patients
undergoing chemotherapy, post-transplant, immunodeficiency, HIV or AIDS, taking
corticosteroids or other immunosuppressive agents. Based on available data,
secondary bacterial infections can be found in more than 20% of critically ill
COVID-19 patients. There are no studies that have compared the incidence of
hospital-acquired pneumonia or ventilation-acquired pneumonia in critically ill
COVID-19 patients with other critical illnesses, so for now it is recommended
to give therapy for co-infection with COVID-19 the same pattern as other
critical illness pathogens. These bacteria include Staphylococcus aureus,
Enterobacterales, Pseudomonas aeruginosa, Acinobacter baumannii, and
Haemophilus influenzae. The choice of antibiotics given can follow the pattern
of local antibiotic resistance There are no studies that have compared the
incidence of hospital-acquired pneumonia or ventilation-acquired pneumonia in
critically ill COVID-19 patients with other critical illnesses, so for now it
is recommended to give therapy for co-infection with COVID-19 the same pattern
as other critical illness pathogens. These bacteria include Staphylococcus
aureus, Enterobacterales, Pseudomonas aeruginosa, Acinobacter baumannii, and
Haemophilus influenzae. The choice of antibiotics given can follow the pattern
of local antibiotic resistance There are no studies that have compared the
incidence of hospital-acquired pneumonia or ventilation-acquired pneumonia in
critically ill COVID-19 patients with other critical illnesses, so for now it
is recommended to give therapy for co-infection with COVID-19 the same pattern
as other critical illness pathogens. These bacteria include Staphylococcus
aureus, Enterobacterales, Pseudomonas aeruginosa, Acinobacter baumannii, and
Haemophilus influenzae. The choice of antibiotics given can follow the pattern
of local antibiotic resistance Pseudomonas aeruginosa, Acinobacter baumannii,
and Haemophilus influenzae. The choice of antibiotics given can follow the
pattern of local antibiotic resistance Pseudomonas aeruginosa, Acinobacter
baumannii, and Haemophilus influenzae. The choice of antibiotics given can
follow the pattern of local antibiotic resistance (Huang et al., 2020). In this patient,
because the patient is in a critical degree and has comorbid HIV, so there is a
place for this patient to be given antibiotics. In patients with severe inpatient
pneumonia, the standard regimen given is beta lactam with macrolides, or beta
lactam with fluoroquinolones.
beta
lactam in the form of ceftriaxone and fluoroquinolone in the form of
levofloxacin. The recommended ceftriaxone is 1-2 grams per day, this patient
was given ceftriaxone 2x1 gram. Ceftriaxone is administered intravenously in
the form of a powder for injection of 1 gram per vial. For levofloxacin, the
recommended dose is 750 mg per day. In this patient levofloxacin was given as
much as 1x750 mg. Levofloxacin is available as an infusion solution. Based on
existing studies there is no difference in outcome from administration of beta
lactam and macrolides compared to fluoroquinolone monotherapy (WHO, n.d.).
Co-trimoxazole
is routinely given as a prophylaxis to HIV patients with WHO stage 3 or 4, CD4
levels ≤ 200 cells/uL, and/or pregnant women. Co-trimoxazole is recommended to
be given 2 weeks before starting anti-retroviral therapy (ARV) to avoid
interactions between co-trimoxazole and ARV. In conditions where malaria and/or
other bacterial infections are found, co-trimoxazole should be given regardless
of WHO stage or CD4 count. The dose of co-trimoxazole for prophylaxis in HIV
patients is 1x960 mg or 2x480 mg orally. Co-trimoxazole prophylaxis aims to
reduce mortality due to infection by Pneumocystis jirovecii (Cooper et al., 2020).
In
COVID-19 infection, co-trimoxazole prophylaxis is also considered
anti-inflammatory. Co-trimoxazole can reduce pro-inflammatory markers such as C
reactive protein (CRP) and tumor necrosis factor-alpha. Co-trimoxazole can
suppress oxidative stress, especially in critically ill COVID-19 patients (Dandachi et al., 2021; Sun et al., 2021).
Other
drugs such as enoxaparin are prophylactic anticoagulants given especially to
severe and critical COVID-19 patients. 16 In a study by Klok et al (2020) it was found that complications in
severe COVID-19 patients in the ICU covered 31% of cases of thrombosis, 27%
venous thromboembolic cases, and 3.7% of arterial thrombotic cases. In COVID-19
patients, thrombus forms in the pulmonary arteries (Pulmonary Intravascular
Coagulopathy/PIC). PIC itself will stimulate an inflammatory reaction resulting
in hyperinflammation. In addition, the release of cytokines (IL-2, IL-6, and
TNF) will stimulate coagulopathy and systemic thrombosis. Continuous
coagulation and thrombosis will cause Multi Organ Dysfunction and then
Multi-organ failure. 18 Based on a study by Novainti Fatli Azizah et al., It
was reported that Enoxaparin 2x1596 ug/L reduced the average d-dimer.
Prophylactic anticoagulants can be given while the patient is being treated. If
the patient's condition has gradually improved, the patient can be actively
mobilized, the risk of thrombosis must be reassessed. If it is not high then
the anticoagulant can be stopped (Härter et al., 2020).
Cycle
threshold value (CT value) qualitatively describes the amount of viral RNA
detected. Nowadays, many people conclude that a lower CT value indicates a
greater amount of virus (Sarkar et al., 2020). CT value <21
has a three times greater risk of mortality. The CT value is found to be lowest
when new symptoms appear (Rabaan et al., 2021). Study by Aranha
et al (2020) reported that
patients with a CT value of 31 or greater required a shorter time for RNA
clearance. Based on a study by Brandolini et al (2015) showed that in
patients with a number of viruses per uL of 102-106, the CT value was found to
be 32 to 17. In this patient who was admitted with a CT value of 11.64 when
repeated swab evaluations were performed, consistent positive results were
found for quite a long time. This is associated with a weak initial CT, the
patient's immune condition is weak so that the clearance of RNA lasts longer.
Treatment
for COVID-19 in people with HIV is the same as for those who do not have HIV.
When starting treatment for COVID-19 in patients with HIV, clinicians should be
aware of potential drug-drug interactions and overlapping toxicities among
COVID-19 treatments, ARV drugs, antimicrobial therapy, and other drugs.
Treatment options for non-hospitalized patients with HIV include
ritonavir-boosted nirmatrelvir (Paxlovid), intravenous remdesivir,
bebtelovimab, and molnupiravir. Drug-drug interactions are a particular concern
with ritonavir-enhanced nirmatrelvir. People with HIV on ritonavir- or
cobicistat-based HAART can receive 5-day therapy of ritonavir-enhanced
nirmatrelvir to treat COVID-19 without changing or interrupting their HAART (Cooper et al., 2020).
In
hospitalized patients, the appropriate treatment strategy depends on the
severity of the disease. Both tocilizumab and dexamethasone, which are
recommended for some patients with severe or critical COVID-19, are
immunosuppressive agents. The safety of using these drugs in immunocompromised
patients, including those with advanced HIV, has not been studied. Therefore,
patients with advanced HIV receiving these drugs should be monitored closely
for secondary infections. Dexamethasone is a dose-dependent inducer of
cytochrome P450 3A4 and has the potential to reduce the levels of certain
antiretroviral drugs. More than a single dose of dexamethasone is not
recommended for patients receiving rilpivirine as part of their ARV regimen (Cooper et al., 2020). Where possible,
ART and opportunistic infection prophylaxis should be continued in patients
with HIV who develop COVID-19, including those requiring hospitalization.
Interruption of treatment can lead to rebound viremia and, in some cases,
emergence of drug resistance. If suitable ARV drugs are not in the hospital
formulary, administer drugs from the patient's home supply, if available (Cooper et al., 2020).
In a
COVID-19 case series with HIV co-infection Cooper et al. Shows that viral load
and CD4 count are variables that influence symptom severity, but are not
related to an individual's susceptibility to COVID-19 infection (Cooper et al., 2020). In early case
series of COVID-19 patients in Europe and the United States, no significant
differences were observed in the clinical outcome of COVID-19 between people
with HIV and people who did not have HIV13. In contrast, more recent reports
show poorer outcomes for patients with HIV and COVID-19, including high
COVID-19 death rates in cohort studies from the United States, United Kingdom,
and South Africa13. In a multicenter cohort study of 286 patients with HIV and
COVID-19 in the United States, a lower CD4 T lymphocyte (CD4) cell count (ie,
<200 cells/mm3) was associated with a higher risk of admission to the intensive
care unit (ICU). ICU), use of invasive mechanical ventilation, or death. This
increased risk was observed even in patients who had achieved HIV virological
suppression (Sun et al., 2021).
In the
study by Huang et al. Regarding the clinical characteristics of COVID-19
patients in Wuhan, the average age of COVID-19 patients found is 49 years. The
study involved 41 subjects, 32% of whom had comorbid diseases such as DM,
hypertension and cardiovascular disease, but none had HIV infection. It was
found that the median time of hospitalization was 7 days after the onset of
symptoms and experiencing dyspnea 8 days after the onset of symptoms. This
study also mentions some of the main symptoms experienced by patients including
fever (98% of subjects), cough (76% of subjects), and myalgia or fatigue in 44%
of subjects (C. Huang et al., 2020).
Another
study by Harter et al. regarding the characteristics of COVID-19 cases with HIV
infection, the average age was 48 years with an age range of 26-82 years. Some
of the main symptoms found in patients include cough (78%), fever (69%),
arthralgia or myalgia (22%), and sore throat (22%) (Härter et al., 2020). Case report by
Patel et al. in 2020 regarding a 37-year-old COVID-19 patient with HIV
infection and an absolute CD4 cell count of 34 cells/µL showing symptoms such
as fever, dry cough, and chest pain since 1 month before being admitted to the
hospital. Physical examination of the patient showed a high body temperature of
38.8°C, oxygen saturation (SpO2) of 85-90% in ambient air, with a high
respiratory rate (40 beats/minute), and a pulse of 119 beats/minute (Patel, 2021). Based on the
case report by Patel et al, the clinical severity of the patient may be
affected by the possibility of secondary infection. Viremia also cannot be
ruled out as a cause of more severe clinical symptoms in patients (Patel, 2021).
In the
case report by Widiasari et al., the first COVID-19 patient with HIV infection
showed normal laboratory and chest X-ray results. The second patient's
laboratory examination showed an increased percentage of neutrophils,
lymphopenia, and thrombocytopenia accompanied by a reticular pattern on the
chest radiograph. The second patient also had chronic symptoms such as weight
loss associated with tuberculous lymphadenitis in addition to signs of acute
infection caused by bacteria or opportunistic infections (Widiasari et al., 2020).
In a study by
Huang et al. in the COVID-19 population, only four patients (10%) had secondary
infections and required intensive care. Laboratory results showed normal
leukocyte values (in 45% of patients), with a mean absolute neutrophil count
of 5 × 103/L, leukopenia occurred in 63% of patients, normal platelet values were
found in 95% of patients, and predominantly decreased liver function and kidney
(Huang et al., 2020).
It is
important to pay attention to the CT Value in monitoring COVID-19 patients. The
CT value or cycle threshold is the thermal cycle due to the fluorescent signal
exceeding the background fluorescence. It is a semi-quantitative measure which
helps in broad categorization of viral genetic material in patient samples
after testing by RT PCR. This can vary and be classified as low, medium, or
high. Standard RT-PCR tests run a maximum of 40 thermal cycles. A low ct
indicates an increased concentration of genetic material, usually correlated
with a high risk of infection. A high Ct value determines a lower risk of
infectivity because it reflects a low concentration of viral genetic material.
However, low viral load can also be caused by the incubation period or the
recovery stage (Kashyap et al., 2020). An inverse
correlation between SARS-CoV-2 Ct values and mortality (Huang et al., 2020). During previous
MERS-CoV and SARS virus pandemics, a similar association of low Ct values
with infection severity was reported (Feikin et al., 2015).
High CT
values were found in several cases as follows (Rabaan et al., 2021); (1) asymptomatic
infection with unknown risk of infectivity, (2) pre-symptomatic
infection which can then progress to symptomatic infection with high viral load
and infectivity, (3) during acute
COVID-19 with a high risk of infectivity but there is interference with the
sample, (4) individuals who are immunocompromised and
hospitalized with critical illness are more likely to shed the potentially
infectious virus longer.
In the
case report, Yousaf et al, showed that a patient with comorbid HIV and
Covid-19, even though he was in clinical recovery and ART, his COVID-19 PCR
test continued to be positive with a ct rRT value.-PCR mean <30, which is
considered secondary to her immunosuppressed state. On examination the patient
was still positive for PCR with a CT value of less than 30 (infectious) for a
total period of 85 days. ct rRT values-PCR began to improve two weeks after
starting ART with a CT Scan reaching a value of 30, considered not infected
after a total of 6 weeks of ART. During this period, her CD4 count gradually
increased to 42 (Yousaf et al., 2021).
It has
been hypothesized that immunosuppression in COVID-19 can delay viral clearance
and prolong the course of the disease. Kanwugu (2021) in his review
showed a strong relationship between HIV and immunosuppression (CD4 count
<200 or ≥200 cells per μL) to increasing the severity of COVID-19 (P = .005)
but not clinical outcome (P = .275). Binary regression analysis of their data
indicated that CD4 counts <200 cells per μL increased the risk of developing
severe COVID-19. Vizcarra et al in their case series also showed that those
with a high number of T cells-Low CD4 may have severe disease and prolonged
viral shedding. Kanwugu et al also pointed out that there is no evidence that
both viral suppression and HAART use have a meaningful impact on COVID severity-19
(Vizcarra et al., 2020).
In Blanco
et al's research related to a series of cases in Barcelona, Spain regarding
COVID-19 with HIV infection by Blanco et al. compared four patients who were on
routine ARVs and had an absolute CD4+ count >200/uL and one patient who was
not on ARVs and had a CD4+ count <200/uL. Two patients who had received ARV
therapy had mild clinical symptoms without laboratory and chest X-ray
abnormalities, two patients who received ARV had moderate symptoms, and one
patient who did not have ARV and had a CD4+ count of 13 Cells/uL had severe
symptoms of COVID-19 with signs of secondary bacterial infection such as an
increase in leukocytes to 14,670 cells per 103/L. Lymphopenia occurred in two
cases with ARV and one case without ARV with the lowest lymphocyte count being
900 cells per 103/L (Blanco et al., 2020).
In the
case report of Wang et. al. show patients with different characteristics. They
reported a COVID-19 patient with HIV infection with a CD4+ count of 34 Cells/µL
having a severe clinical presentation but no leukocytosis or signs of secondary
infection, especially bacterial infection (M. Wang et al., 2020). Other secondary
infections that can occur in HIV patients are Pneumocystis carinii
(Pneumocystis pneumonia [PCP]), tuberculosis, Hepatitis B, Hepatitis C,
Cryptococcal Meningitis, and Toxoplasmosis. Can be considered to carry out a
clinical evaluation of infection if a COVID-19 patient with HIV infection is
found to improve the patient's prognostic results, especially HIV / AIDS
patients who have a CD4 + count < 200 Cells / uL (Vaillant & Up, 2021).
Secondary
infection is also often associated with Covid-19 patients with HIV
comorbidities. Based on research conducted by Huson et al. Shows that patients
with bacteremia have an average increase in leukocytes in HIV patients lower
than non-HIV patients. The study was conducted on patients with an average CD4+
of 150 cells/µL (Huson et al., 2014). In the case
series reported by Blanco et al, HIV patients who had CD4+ counts >200
cells/uL and were already taking antiretroviral drugs routinely showed higher
leukocyte counts than HIV patients with CD4+ counts <200 cells/uL and had
not received ARVs. Lymphopenia and thrombocytopenia are accompanied by a
reticular pattern on the chest radiograph consistent with signs of viral
infection. Mild anemia can be caused by chronic inflammation from tuberculosis
and HIV. Nutritional intake from food can also affect the occurrence of anemia
in patients. Severe lymphopenia in HIV/AIDS patients with COVID-19 can affect
the severity of symptoms (Blanco et al., 2020).
Treatment
recommendations for COVID-19 patients with HIV co-infection are similar to
those for COVID-19 without HIV infection. The high risk of secondary infection
in HIV/AIDS patients makes optimization of secondary infection therapy very
important (Widiasari et al., 2020). Giving systemic
steroids to COVID-19 patients with HIV infection is still recommended,
especially in patients with clinically severe COVID-19 or with secondary
infection in severe forms of PCP, although systemic steroid administration in a
study conducted by Huang (2020) and Wang 2020
said it could slow down virus clearance and extend the virus shedding period (Wang et al., 2020).
The
recommendation issued by British and American health agencies for people with
HIV during a pandemic is to ensure that they have a good supply of ARVs and
that they are vaccinated against Influenza and Pneumococci regularly. To date,
there have been no specific reports regarding the relationship between the type
of ARV used and the severity of COVID-19 symptoms in patients with HIV, but
there are case series that show clinical differences in patients with different
ARV histories. A case series report by Blanco et al (2020) showed that two
patients taking the combination ARVs tenofovir alafenamide, emtricitabine, and
Darunavir-boosted Cobicistat had mild symptoms of COVID-19 and two patients
taking the combination ARVs abacavir, lamivudine, and dolutegravir had moderate
to severe COVID-19 presentations and required intensive care. The combination
of Lopinavir and Ritonavir in in vitro studies may shorten the viral shedding
period, but its effectiveness in COVID-19 clinical studies has not been shown
to significantly improve patient outcomes compared to standard therapy (Yan et al., 2020).
The
outcome of COVID-19 patients can be assessed based on the length of time to
achieve a negative result in nasopharyngeal RT-PCR swab and the risk of
morbidity and mortality. Case report by Wang et al. in 2020 regarding COVID-19
patients with HIV infection who had CD4+ counts <200 Cells/µL reported only
getting positive results on the first RT-PCR and negative on 3 RT-PCR
nasopharyngeal swab evaluations. This is due to the base value of each CT, but
cannot be compared due to using kits with different target genes. Another
possibility is that the patient's second shedding of virus on the day of
evaluation was found in the sputum, thus not being detected in the
nasopharyngeal swab specimen27. The two cases reported by Menghua et.al showed
long COVID 19 cases and it took 28 days to get a negative RT-PCR swab, but, in
this case, RT-PCR was performed on the sputum specimen. This condition could be
due to prolonged viral shedding in patients associated with impaired cellular
function of CD4+ cells even though CD4+ cell counts are within normal limits (Wang et al., 2020).
CONCLUSION
Mr. Case
Rn, 37 years old, is a case of critical degree Covid 19 pneumonia accompanied
by stage II HIV. The patient was treated in the covid icu for 15 days and in
the isolation room for 16 days. During the treatment, an evaluation swab
examination was carried out 4 times to get positive results. The patient
started ARV treatment after 15 days of treatment. The patient went home from
the hospital, doing independent isolation.
REFERENCES
Blanco, J. L., Ambrosioni, J.,
Garcia, F., Martínez, E., Soriano, A., Mallolas, J., & Miro, J. M. (2020).
COVID-19 in patients with HIV: clinical case series. The Lancet HIV, 7(5),
e314–e316.
Burhan, E. (2020). Pedoman
tatalaksana COVID-19.
Cooper, T. J., Woodward, B. L., Alom,
S., & Harky, A. (2020). Coronavirus disease 2019 (COVID‐19) outcomes in
HIV/AIDS patients: a systematic review. HIV Medicine, 21(9),
567–577.
Dandachi, D., Geiger, G., Montgomery,
M. W., Karmen-Tuohy, S., Golzy, M., Antar, A. A. R., Llibre, J. M., Camazine,
M., Díaz-De Santiago, A., & Carlucci, P. M. (2021). Characteristics,
comorbidities, and outcomes in a multicenter registry of patients with human
immunodeficiency virus and coronavirus disease 2019. Clinical Infectious
Diseases, 73(7), e1964–e1972.
Feikin, D. R., Alraddadi, B., Qutub,
M., Shabouni, O., Curns, A., Oboho, I. K., Tomczyk, S. M., Wolff, B., Watson,
J. T., & Madani, T. A. (2015). Association of higher MERS-CoV virus load
with severe disease and death, Saudi Arabia, 2014. Emerging Infectious
Diseases, 21(11), 2029.
Härter, G., Spinner, C. D., Roider,
J., Bickel, M., Krznaric, I., Grunwald, S., Schabaz, F., Gillor, D., Postel,
N., & Mueller, M. C. (2020). COVID-19 in people living with human
immunodeficiency virus: a case series of 33 patients. Infection, 48,
681–686.
Huang, C., Wang, Y., Li, X., Ren, L.,
Zhao, J., Hu, Y., Zhang, L., Fan, G., Xu, J., & Gu, X. (2020). Clinical
features of patients infected with 2019 novel coronavirus in Wuhan, China. The
Lancet, 395(10223), 497–506.
Huang, J.-T., Ran, R.-X., Lv, Z.-H.,
Feng, L.-N., Ran, C.-Y., Tong, Y.-Q., Li, D., Su, H.-W., Zhu, C.-L., & Qiu,
S.-L. (2020). Chronological changes of viral shedding in adult inpatients with
COVID-19 in Wuhan, China. Clinical Infectious Diseases, 71(16),
2158–2166.
Huson, M. A. M., Stolp, S. M., van
der Poll, T., & Grobusch, M. P. (2014). Community-acquired bacterial
bloodstream infections in HIV-infected patients: a systematic review. Clinical
Infectious Diseases, 58(1), 79–92.
Joob, B. W. (2020). V. SARS-CoV-2
and HIV. J Med Virol. https://pubmed.ncbi.nlm.nih.gov/32220066/
Jordan, R. E., Adab, P., & Cheng,
K. (2020). Covid-19: risk factors for severe disease and death. In Bmj
(Vol. 368). British Medical Journal Publishing Group.
Kanwugu, O. N., & Adadi, P.
(2021). HIV/SARS‐CoV‐2 coinfection: a global perspective. Journal of Medical
Virology, 93(2), 726–732.
Kashyap, B., Goyal, N., &
Prakash, A. (2020). COVID diagnostics: Do we have sufficient armamentarium for
the present and the unforeseen? Indian Journal of Medical Specialities, 11(3),
117.
Patel, R. H. (2021). Clinical
outcomes and prognosis of patients with HIV and SARS‐CoV‐2 coinfection. Journal
of Medical Virology, 93(1), 105.
Rabaan, A. A., Tirupathi, R., Sule,
A. A., Aldali, J., Mutair, A. Al, Alhumaid, S., Gupta, N., Koritala, T.,
Adhikari, R., & Bilal, M. (2021). Viral dynamics and real-time RT-PCR Ct
values correlation with disease severity in COVID-19. Diagnostics, 11(6),
1091.
Rodger, A. J., Cambiano, V., Bruun,
T., Vernazza, P., Collins, S., Degen, O., Corbelli, G. M., Estrada, V.,
Geretti, A. M., & Beloukas, A. (2019). Risk of HIV transmission through
condomless sex in serodifferent gay couples with the HIV-positive partner
taking suppressive antiretroviral therapy (PARTNER): final results of a
multicentre, prospective, observational study. The Lancet, 393(10189),
2428–2438.
Sarkar, B., Sinha, R. N., &
Sarkar, K. (2020). Initial viral load of a COVID-19-infected case indicated by
its cycle threshold value of polymerase chain reaction could be used as a
predictor of its transmissibility-An experience from Gujarat, India. Indian
Journal of Community Medicine: Official Publication of Indian Association of
Preventive & Social Medicine, 45(3), 278.
Siedner, M. J., & Triant, V.
(2019). Undetectable= untransmittable and your health: the personal benefits of
early and continuous therapy for HIV infection. In The Journal of infectious
diseases (Vol. 219, Issue 2, pp. 173–176). Oxford University Press US.
Sun, J., Patel, R. C., Zheng, Q.,
Madhira, V., Olex, A. L., Islam, J. Y., French, E., Chiang, T. P.-Y., Akselrod,
H., & Moffitt, R. (2021). COVID-19 disease severity among people with HIV
infection or solid organ transplant in the United States: a nationally-representative,
multicenter, observational cohort study. Medrxiv.
Vaillant, A. A. J., & Naik, R.
(2021). HIV-1 associated opportunistic infections. In StatPearls [Internet].
StatPearls Publishing.
Vishnevetsky, A., & Levy, M.
(2020). Rethinking high-risk groups in COVID-19. Multiple Sclerosis and
Related Disorders, 42.
Vizcarra, P., Pérez-Elías, M. J.,
Quereda, C., Moreno, A., Vivancos, M. J., Dronda, F., Casado, J. L., Moreno,
S., Pérez-Elías, M. J., & Fortún, J. (2020). Description of COVID-19 in
HIV-infected individuals: a single-centre, prospective cohort. The Lancet
HIV, 7(8), e554–e564.
Wang, M., Luo, L., Bu, H., & Xia,
H. (2020). One case of coronavirus disease 2019 (COVID-19) in a patient
co-infected by HIV with a low CD4+ T-cell count. International Journal of
Infectious Diseases, 96, 148–150.
Wang, W., Xu, Y., Gao, R., Lu, R.,
Han, K., Wu, G., & Tan, W. (2020). Detection of SARS-CoV-2 in different
types of clinical specimens. Jama, 323(18), 1843–1844.
WHO. (n.d.). Coronavirus
(COVID-19) Dashboard. WHO Coronavirus (COVID-19) Dashboard With Vaccination
Data. Retrieved October 24, 2022, from https://covid19.who.int/
Widiasari, N. P. A., Arisanti, N. L.
P. E., Rai, I. B. N., & Iswari, I. S. (2020). Two Serial Case of
Coronavirus Disease-19 Patients Coinfected with HIV: Comparison of
Pre-anti-Retroviral (art) and on Art Patient. Open Access Macedonian Journal
of Medical Sciences, 8(T1), 416–421.
Yan, D., Liu, X.-Y., Zhu, Y., Huang,
L., Dan, B., Zhang, G., & Gao, Y. (2020). Factors associated with prolonged
viral shedding and impact of lopinavir/ritonavir treatment in hospitalised
non-critically ill patients with SARS-CoV-2 infection. European Respiratory
Journal, 56(1).
Yousaf, M., Hameed, M., Alsoub, H.,
Khatib, M., Jamal, W., & Ahmad, M. (2021). COVID‐19: Prolonged viral
shedding in an HIV patient with literature review of risk factors for prolonged
viral shedding and its implications for isolation strategies. Clinical Case
Reports, 9(3), 1397–1401.
Zaim, S., Chong, J.,
Sankaranarayanan, V., & Harky, A. (2020). COVID-19 and Multiorgan
Response. Curr Probl Cardiol. https://pubmed.ncbi.nlm.nih.gov/32439197/
Zheng, Z., Peng, F., Xu, B., Zhao,
J., Liu, H., Peng, J., Li, Q., Jiang, C., Zhou, Y., & Liu, S. (2020). Risk
factors of critical & mortal COVID-19 cases: A systematic literature review
and meta-analysis. Journal of Infection, 81(2), e16–e25.
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