Case report
COVID-19 pneumonia in an HIV-positive woman on antiretroviral therapy and undetectable viral load in Porto Alegre, Brazil
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"autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Naira Bicudo, Eliana Bicudo, Julia Duarte Costa, Julliana Alline Leite Porto Castro, Gustavo Barcelos Barra" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Naira" "apellidos" => "Bicudo" ] 1 => array:2 [ "nombre" => "Eliana" "apellidos" => "Bicudo" ] 2 => array:2 [ "nombre" => "Julia Duarte" "apellidos" => "Costa" ] 3 => array:2 [ "nombre" => "Julliana Alline Leite Porto" "apellidos" => "Castro" ] 4 => array:2 [ "nombre" => "Gustavo Barcelos" "apellidos" => "Barra" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1413867020301070?idApp=UINPBA00003Y" "url" => "/14138670/0000002400000005/v5_202012221025/S1413867020301070/v5_202012221025/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "COVID-19 pneumonia in an HIV-positive woman on antiretroviral therapy and undetectable viral load in Porto Alegre, Brazil" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "455" "paginaFinal" => "457" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Murillo Machado Cipolat, Eduardo Sprinz" "autores" => array:2 [ 0 => array:3 [ "nombre" => "Murillo Machado" "apellidos" => "Cipolat" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "Eduardo" "apellidos" => "Sprinz" "email" => array:1 [ 0 => "esprinz@hcpa.edu.br" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital de Clínicas de Porto Alegre, Infectious Diseases Service, Porto Alegre, RS, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidade Federal de Rio Grande do Sul, Faculdade de Medicina, Porto Alegre, RS, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 808 "Ancho" => 900 "Tamanyo" => 48781 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray with peripheral opacities in inferior lobes of both lungs.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">COVID-19, caused by the severe acute respiratory syndrome coronavirus type-2 (SARS-CoV-2), has been declared a pandemic in March 2020, following the first case reported in Wuhan, China in December 2019. Some patients, such as those suffering from cardiovascular disease, diabetes mellitus and obesity, were soon identified at greater risk for worse clinical outcomes. Nevertheless, there is still a lot to be discovered regarding this disease. In this context, not only the risk of COVID-19 complications among people living with HIV (PLWH) remains uncertain, but also the potential protective benefits of antiretroviral (ARV) drugs.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite of more than 12 million cases of COVID-19 worldwide as early July, reports of HIV/Sars-CoV-2 co-infection are still uncommon,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> with the first known case in the USA only being reported on May 22, 2020,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> People living with HIV accounted for only 1% of 16,749 patients with COVID-19 hospitalized in the United Kingdom, on a large prospective observational cohort study, with HIV having no impact on survival.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Thereafter, the prognosis of PLWH after the diagnosis of COVID-19 has also been a subject of debate.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> While some researchers believe that HIV immunosuppression could result in greater susceptibility to SARS-CoV-2 infection,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> others believe that these patients would be at a lower risk of complications, since impairment in cellular immunity might be associated with less inflammation,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> reducing the incidence of cytokine storm which has been associated with more severe cases of COVID-19.</p><p id="par0015" class="elsevierStylePara elsevierViewall">There is also some controversy about the potential advantages against SARS-CoV-2 from being on ARVs.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> There is some <span class="elsevierStyleItalic">in vitro</span> evidence that these drugs could have an impact against this virus.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> Herein we present the case of an HIV-infected woman on antiretroviral therapy who was hospitalized at our center with COVID-19 pneumonia.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 63-year-old woman was admitted to COVID-19 Unit at Hospital de Clinicas de Porto Alegre (HCPA), on southern Brazil, on May, 2020. The patient had been diagnosed with HIV infection in 2005, and was on tenofovir (TDF), lamivudine (3TC), and dolutegravir (DTG) since November 2019 (before she was on atazanavir/ritonavir, switched for DTG). Her viral load had been undetectable for a long time and her CD4+ cell count was 426 cells/mm<span class="elsevierStyleSup">3</span> (CD4/CD8 ratio 1.25). Systemic arterial hypertension (SAH), well controlled with hydrochlorothiazide and losartan, was the other comorbidity she had.</p><p id="par0025" class="elsevierStylePara elsevierViewall">At presentation, she complained of fever (39 °C), myalgia, inappetence, nausea, abdominal pain, diarrhea, hyposmia and hypogeusia, in addition to cough and dyspnea for a week. Upon admission, white blood cells (WBC) count was 9250 cells/mm<span class="elsevierStyleSup">3</span> (76% neutrophils, and 16% lymphocytes). She had elevated C-reactive protein (65.5 mg/L), total creatine kinase (307 U/L) and lactate dehydrogenase (316 U/L). Serum creatinine was 0.84 mg/dL and she had no abnormalities in clotting tests, including a D-Dimer level of 0.42 ug/mL (with our reference value being up to 0.5 ug/mL). First arterial blood gas analysis (ABG) was performed with the patient on supplemental oxygen through a nasal cannula, but she did not present hypoxemia, with a 107 mmHg pO<span class="elsevierStyleInf">2</span> and a peripheral oxygen saturation (SpO<span class="elsevierStyleInf">2</span>) of 98.5%. Chest X-ray exhibit opacities in middle thirds of both lungs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Sars-CoV-2 was detected by RT-PCR in nasopharyngeal secretion swab.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was treated with supportive measures that included oxygen via nasal cannula and received antibiotic therapy with amoxicillin/clavulanate for a total of seven days. After giving consent, she was randomized to one of the arms of a randomized clinical trial (Coalition-1 trial<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>) and received hydroxychloroquine 400 mg bid plus azithromycin 500 mg per oral according to trial protocol, with no side effects related to any of these therapies during this period. Even though she presented some severity markers on admission, she had a favorable clinical evolution, with no need for treatment in ICU or requiring more invasive forms of oxygen therapy, being discharged in good clinical conditions seven days after hospitalization.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="par0035" class="elsevierStylePara elsevierViewall">To our knowledge, this is the first reported case of COVID-19 disease in an HIV-infected individual in Brazil and remains the only one that we had the opportunity to care. This finding is of special interest, as Porto Alegre, the capital of the southernmost state of Brazil (Rio Grande do Sul), is one of the cities with highest HIV incidence in Brazil.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> This report has the purpose to illustrate the several peculiarities of SARS-CoV-2 infection worldwide. Although the patient presented a severe course of COVID-19, the ARVs she was taking did not protect her from acquiring the infection.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Among the drugs used to treat HIV, lopinavir/ritonavir was the first to assessed against SARS-CoV-2. In spite of the studies in 2003 during SARS epidemic showing a decrease in mortality, intubation rates and unfavorable outcomes on SARS with the use of lopinavir/ritonavir,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> a recent clinical trial showed no benefit of this medication for the treatment of severe cases of COVID-19.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Other combinations of protease inhibitors are under testing, with atazanavir/ritonavir showing greatest inhibitory potential <span class="elsevierStyleItalic">in vitro</span> against SARS-CoV-2.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> A clinical trial of darunavir/cobicistat for treatment of COVID-19 is currently on progress in China.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Other ARVs have also shown some activity <span class="elsevierStyleItalic">in vitro</span> and in animal models. DTG, an integrase inhibitor, had demonstrated activity against SARS-CoV-2.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9,15,16</span></a> Likewise, TDF, a nucleotide analogue reverse transcriptase inhibitor widely used in the treatment of HIV and Hepatitis B infections, has emerged as a new investigative agent against COVID-19. It is from the same class as remdesivir, a novel nucleotide analogue that has activity against SARS-CoV-2 <span class="elsevierStyleItalic">in vitro</span><a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and has been recommended for hospitalized patients with severe COVID-19 in many guidelines.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> However, no ARV has demonstrated clinical impact so far.</p><p id="par0045" class="elsevierStylePara elsevierViewall">One of the first published case series, comprising of 33 patients hospitalized for COVID-19 followed up at HIV centers in Germany, suggested that although SARS-CoV-2 infection could occur during treatment with ARVs, these patients did not appear to be at risk for worse clinical outcomes among those with symptomatic COVID-19.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> A recent large Spanish cohort study of 77,590 HIV-infected people on ARVs identified similar risk factors for hospitalization, admission to ICU, and death when compared to the general population.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> However, HIV-infected patients on TDF/FTC had a lower risk of COVID-19 and related hospitalization than those receiving other therapies. Whether the difference observed is due to the profile features of patients using this ART or the direct antiviral effect of the drug is still a matter of debate.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Currently, one trial combining tenofovir-alafenamide/emtricitabine and lopinavir/ritonavir to treat COVID-19 patients and another with tenofovir/emtricitabine as pre-exposure prophylaxis against COVID-19 in health care workers are on progress.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In our patient, these ARVs did not prevent SARS-CoV-2 infection. Still, a lot is still to come regarding this coronavirus infection and the clinical course in HIV-infected individuals and the possible impact of ARVs.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:3 [ "identificador" => "xres1439308" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1313626" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusion" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-06-06" "fechaAceptado" => "2020-07-24" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1313626" "palabras" => array:4 [ 0 => "SARS-CoV-2" 1 => "COVID-19" 2 => "HIV" 3 => "AIDS" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">COVID-19 pandemic has been a problem worldwide. It is important to identify people at risk of progressing to severe complications and to investigate if some existing antivirals could have any action against SARS-CoV-2. In this context, HIV-infected individuals and antiretroviral drugs might be included, respectively. Herein we present the case of a 63-year-old HIV-infected woman with undetectable viral load, on dolutegravir, tenofovir and lamivudine, who was hospitalized due to COVID-19 pneumonia. In spite of having some clinical markers of severity on admission, the patient improved and was discharged after a week. To our knowledge, this is the first report of severe SARS-CoV-2 infection in an HIV-infected individual in Brazil.</p></span>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 808 "Ancho" => 900 "Tamanyo" => 48781 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray with peripheral opacities in inferior lobes of both lungs.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:21 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "COVID-19 in patients with HIV: clinical case series" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 25 | 41 | 66 |
| 2024 September | 42 | 24 | 66 |
| 2024 August | 71 | 44 | 115 |
| 2024 July | 73 | 39 | 112 |
| 2024 June | 79 | 26 | 105 |
| 2024 May | 43 | 24 | 67 |
| 2024 April | 66 | 22 | 88 |
| 2024 March | 73 | 36 | 109 |
| 2024 February | 66 | 26 | 92 |
| 2024 January | 41 | 31 | 72 |
| 2023 December | 36 | 43 | 79 |
| 2023 November | 56 | 50 | 106 |
| 2023 October | 60 | 32 | 92 |
| 2023 September | 58 | 56 | 114 |
| 2023 August | 44 | 22 | 66 |
| 2023 July | 43 | 29 | 72 |
| 2023 June | 50 | 26 | 76 |
| 2023 May | 63 | 35 | 98 |
| 2023 April | 71 | 23 | 94 |
| 2023 March | 115 | 42 | 157 |
| 2023 February | 99 | 30 | 129 |
| 2023 January | 56 | 15 | 71 |
| 2022 December | 117 | 35 | 152 |
| 2022 November | 88 | 42 | 130 |
| 2022 October | 110 | 23 | 133 |
| 2022 September | 88 | 50 | 138 |
| 2022 August | 75 | 45 | 120 |
| 2022 July | 68 | 46 | 114 |
| 2022 June | 83 | 46 | 129 |
| 2022 May | 92 | 34 | 126 |
| 2022 April | 116 | 40 | 156 |
| 2022 March | 129 | 62 | 191 |
| 2022 February | 118 | 54 | 172 |
| 2022 January | 127 | 52 | 179 |
| 2021 December | 89 | 47 | 136 |
| 2021 November | 70 | 34 | 104 |
| 2021 October | 58 | 62 | 120 |
| 2021 September | 66 | 58 | 124 |
| 2021 August | 62 | 44 | 106 |
| 2021 July | 104 | 36 | 140 |
| 2021 June | 72 | 48 | 120 |
| 2021 May | 96 | 63 | 159 |
| 2021 April | 193 | 135 | 328 |
| 2021 March | 157 | 53 | 210 |
| 2021 February | 111 | 33 | 144 |
| 2021 January | 120 | 44 | 164 |
| 2020 December | 186 | 42 | 228 |
| 2020 November | 182 | 47 | 229 |
| 2020 October | 93 | 42 | 135 |
| 2020 September | 156 | 61 | 217 |
| 2020 August | 16 | 6 | 22 |
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