The patient, a 32-year-old man, sought medical care in a local hospital on 30 January 2020 (day 1) for chief complaints of fever, dizziness and dry cough for 6 days. He had tried cephalosporin and paracetamol by himself without efficiency. He denied any potential contact with coronavirus disease-2019 (COVID-19) patients or living in epidemic areas. This patient was diagnosed with HIV infection 12 years ago, and initiated antiretroviral therapy containing zidovudine (300 mg twice/day), lamivudine (300 mg once/day) and efavirenz (600 mg once/night) 6 years ago with CD4+ T-cells count of 294 cells/μl. This regimen was maintained and recent CD4+ T-cell count on October 2019 elevated to 430 cells/μl. On admission, his temperature was 37.8 °C (Fig. 1) and oxygen saturation was around 98% with 33% oxygen inhalation. His white blood cells (WBC) count was 3.7 × 109/l with decreased lymphocytes (1.04 × 109/l), whereas it was 3.26 × 109/l 4 months previously. His C-reactive protein (CRP) was 15.5 mg/l and CD4+ T-cell count was 324 cells/μl. Chest computed tomography (CT) image showed multifocal bilateral multifocal ground-glass opacities (GGOs) (Fig. S1, http://links.lww.com/QAD/B743). In consideration of no COVID-19 contact, piperacillin/tazobactam, levofloxacin and oseltamivir were given. On day 3, his temperature maintained at over 39 °C and WBC count decreased to 2.6 × 109/l with a significant lymphopenia of 0.71 × 109/l and CRP was 15.5 mg/l. Rechecked chest CT showed progressed GGOs and consolidations (Fig. S1, http://links.lww.com/QAD/B743). Imipenem/cilastatin was used. Peak temperature decreased to around 38 °C. With concern of possible severe acute respiratory syndrome (SARS)-CoV-2 infection, nucleic acid detection of sputum was performed on day 4 and the result was shown to be positive on day 5. Detections of other respiratory viruses including influenza A/B, adenovirus, respiratory syncytial virus and parainfluenza virus were all negative. Lopinavir/ritonavir (LPV/r, 400 mg/100 mg twice/day) combined with interferon-α inhalation was given on day 5 to take the place of previous prescriptions, and efavirenz was stopped.
Since diagnosed of COVID-19, he was transferred to our center on day 7, and arbidol (200 mg three times/day) was added to his treatment. Chest CT on day 8 showed apparent absorption of all lesions (Fig. S1, http://links.lww.com/QAD/B743), and his lymphocyte count was 1.5 × 109/l. CRP returned to normal. Detection of SARS-CoV-2 in sputum on day 8 turned negative and stayed negative until discharge. He kept afebrile since day 5. And, on day 12, rechecked chest CT showed lesions similar to that on day 8 (Fig. S1, http://links.lww.com/QAD/B743). On days 10 and 13, we tested SARS-CoV-2 in stools and both results were negative. On day 14, the patient was discharged. He denied any comfortabilities in a follow-up visit 2 weeks later. Laboratory tests showed the WBC count was 6.6 × 109/l, with a normal lymphocytes count (1.8 × 109/l) and a chest CT image showed completed absorption of all lesions.
To our knowledge, this is the first case report to describe SARS-CoV-2 infection in a patient with AIDS. Similarly, low morbidity of co-infection of coronavirus and HIV was also found in patients with SARS and Middle East respiratory syndrome (MERS) as reported previously [1,2]. Defect of immunity was regarded to be one potential susceptibility towards COVID-19 in patients with older age and malignancies [3,4]. However, the immunocompromised states of AIDS patients seemed to have no relevance with respect to COVID-19. One possible reason might be that protease inhibitors were used in some AIDS patients, which were reported to have an antiviral effect towards coronavirus [5,6]. Meanwhile, we speculated that AIDS patients were more likely to wear protective equipment because of concerns of opportunistic infections, and AIDS patients with mild or moderate symptoms might avoid going to see a doctor for personal reasons , which might lead to an extra transmission risk of SARS-CoV-2.
Even through, at the beginning of admission, this patient had persistent high fever with multifocal lesions on the chest CT, durations of symptoms and of lesion progression on the CT image were similar to other moderate COVID-19 patients [8,9]. One explanation might be that impaired immunity of AIDS patients would attenuate the immune response towards coronavirus, which was supposed to cause more damage to the lungs . Meanwhile, immune dysfunction was also regarded to delay the clearance of virus. However, paradoxically, the duration of positive RT-PCR results of SARS-CoV-2 in this patient was shorter than the average level . As LPV/r and arbidol were used after this patient was afebrile, it was hard to conclude from this patient that LPV/r and arbidol could benefit patients with respect to coronavirus clearance. Meanwhile, attention should be paid to irregularities in the administration of antibiotics in AIDS patients with fever during this period. More data are needed to better understand the pathogenesis and prognosis in patients with coinfection of SARS-CoV-2 and HIV.
We appreciate all of the clinical providers, nurses and scientific researchers for their efforts in fighting COVID-19.
Sources of Funding: This work was supported by National Science and Technology Major Project (Dr Su; 2018ZX10715014-004-002).
Conflicts of interest
There are no conflicts of interest.
1. Wong AT, Tsang OT, Wong MY, Lim WL, Zheng BJ, Lee SS, et al. PMH SARS Study Group. Coronavirus infection in an AIDS patient
2. Shalhoub S, AlZahrani A, Simhairi R, Mushtaq A. Successful recovery of MERS CoV pneumonia in a patient with acquired immunodeficiency syndrome: a case report
. J Clin Virol
3. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China
4. Liang W, Guan W, Chen R, Wang W, Li J, Xu K, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China
. Lancet Oncol
5. Cao B, Wang Y, Wen D, Liu W, Wang J, Fan G, et al. A trial of lopinavir-ritonavir in adults hospitalized with severe COVID-19
. N Engl J Med
6. Yao TT, Qian JD, Zhu WY, Wang Y, Wang GQ. A systematic review of lopinavir therapy for SARS coronavirus and MERS coronavirus-A possible reference for coronavirus disease-19 treatment option
. J Med Virol
7. Rueda S, Mitra S, Chen S, Gogolishvili D, Globerman J, Chambers L, et al. Examining the associations between HIV-related stigma and health outcomes in people living with HIV/AIDS: a series of meta-analyses
. BMJ Open
8. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study
9. Pan F, Ye T, Sun P, Gui S, Liang B, Li L, et al. Time course of lung changes on chest CT during recovery from 2019 novel coronavirus (COVID-19) pneumonia
10. Channappanavar R, Perlman S. Pathogenic human coronavirus infections: causes and consequences of cytokine storm and immunopathology
. Semin Immunopathol