In middle February, to move suspected cases in Hubei province to care, the diagnosis criteria of COVID-19 changed to 1) living in the epidemic center, 2) presented with typical symptoms of COVID-19, 3) the radiographic presentation showed ground-glass opacities (GGO) and interstitial pneumonia, no matter the SARS-CoV-2 nucleic acid test (NAT) is negative or positive2. This change quickly moved many suspected cases to treatment but increased the opportunity of misdiagnoses3. The two cases discussed in this commentary piece are examples of the misdiagnosis. These two cases presented high fever and dyspnea on admission to hospitals in February 2020 (35 days and 11 days from the onset of the symptoms to the date of admission), both had GGO and interstitial pneumonia in chest CT, and were NAT negative for SARS-CoV-2 before admission (Table).
After charged into isolated wards and treated with anti-viral medications plus corticosteroids, patient one (P1) progressively deteriorated in the symptoms, while patient two (P2) retained the symptoms during this treatment. For P1, he concealed that he was living with HIV, and the NAT testing turned positive on day nine after admission. The specific antibodies for SARS-CoV-2 were negative on day 24 of admission and turned to IgM positive on day 28 (Figure). After acquired his HIV positive result, he was considered as PCP and was treated with trimethoprim-sulfamethoxazole (TMP/SMZ) and then switched to clindamycin because the patient was allergic to TMP/SMZ on day 31, and the status of the patient was improved soon. The patient was considered to be infected with SARS-CoV-2 in the isolation wards and finally turned positive after the admission. To be noted, on the 65th day after he was tested positive of NAT, both IgM and IgG turned negative, which indicated that effective immune defense against SARS-CoV-2 was hard to build in PLWHA.
As for P2, the NATs were negative throughout the whole course of the disease, while specific IgM for SARS-CoV-2 was positive on day 18 (which was not tested before), and IgG was positive after that (day 27). After being diagnosed as HIV positive on day 20, the patient was considered and treated as PCP (TMP/SMZ). His status was also improved soon after treatment for PCP. In summary, the chronic onset of his clinical course, high lactate dehydrogenase (LDH), interstitial pneumonia by CT scan, and effective specific treatment for PCP favored the diagnosis for PCP from the onset of the disease. For P2, we can not exclude the possibility that the patient was infected with SARS-CoV-2 in the isolation ward.