Abstract
Editor: Various reports regarding SARS-CoV-2 infections in people living with HIV (PLWHIV) have been published, 1,2 with no differences observed in COVID-19 incidence between PLWHIV and the general population. 3 Little is known about whether PLWHIV could present a more severe form of COVID-19 and require different approaches. We report the case of a 59-year-old male patient, diagnosed with HIV infection 30 years ago, who decided to interrupt antiretroviral treatment 10 years ago, with a story of mechanical mitralic prosthesis positioning on 2018, for which he was taking warfarin.
Patient accessed our emergency department on April 25, 2020, because of fever and dyspnea. Blood examinations showed high lactate dehydrogenase (645 UI/L, reference value [RV] < 250), C-reactive protein (59.2 mg/L, RV <5), and interleukin 6 (75.9 ng/L, RV <4.4), a normal renal (creatinine 0.66 mg/dL, RV 7–45) and liver function (alanine aminotransferase 28 UI/L, RV 7–45), a CD4+ lymphocytes count of 10 cells/mm3, and a CD4/CD8 ratio of 0.02. COVID-19 was suspected but the first molecular assay for SARS-CoV-2 through nasopharyngeal swab was negative. Chest computed tomography (CT) scan showed ground glass opacities and, finally, a second swab resulted positive for SARS-CoV-2. He was transferred to our infectious diseases unit and hydroxychloroquine and enoxaparin (instead of warfarin) were started.
Given his low CD4+ cell count, other examinations were performed: serum beta-
After 10 days, the patient complained of lower abdominal pain, blood pressure dropped to 70/40 mmHg, and he developed a clinical-laboratoristic pattern of hypovolemic shock (hemoglobin 7.9 g/dL, I troponin 7020 UI/L, RV <57).
We performed an abdomen CT scan that showed a hematoma in the left iliac muscle of the dimensions of 12 × 11 cm with signs of active bleeding. The patient underwent an emergency surgery for devascularization and arterial embolization. After that, he was transferred to ICU where the following CT scan showed a dimensional increasing of the collection (15 cm of diameter after 1 day and 24 cm after 2 days). The patient died 5 days after the admission in ICU.
COVID-19 represents a challenge for clinicians, in terms of both diagnosis and therapeutic strategies. Current evidence supports the use of anticoagulant therapy; however, especially in fragile patients, the potential side effects of drugs should be taken into account. In our case the patient, who presented a gradual worsening in renal function during hospitalization, developed massive bleeding without any major trauma, probably due to impaired clearance of enoxaparin. Another peculiarity is the concomitant AIDS-defining event. A recent case series by Blanco et al. 1 also included a patient with COVID-19 and concomitant pneumocystis pneumonia (PCP). In our case, because of clinical conditions, we started steroid therapy even if guidelines recommended against the use of corticosteroids in COVID-19. 4 However, the benefit of corticosteroids during PCP is well established, and guidelines prompt a rapid introduction of steroid in cases of respiratory failure (PaO2 <70 mmHg or alveolar/arterial gradient >35 mmHg) 5 ; in our case, the patient had a PaO2 of 50 mmHg at admission. In conclusion, our study describes a peculiar case of an HIV-positive individual with COVID-19 and Pneumocystiis pneumonia, who developed fatal bleeding while on anticoagulant therapy. Great attention must be paid to the use of anticoagulants in fragile patients, while clinicians wait for data on the benefit of enoxaparin in COVID-19 from large controlled studies.
Each named author has contributed to conducting the underlying research and drafting the article. In addition, the named authors have no conflict of interest.