On March 21, a 73-year-old man, entered the emergency room complaining of fever and dyspnea progressing over 10 days. Physical examination showed axillary temperature = 38.6ºC, blood pressure BP = 103/73 mmHg, heart rate = 88 bpm, respiratory rate = 39 bpm and pulse oximetry = 89% (O2 nasal cannula with 3 L/min). He was put under non-rebreather mask with 10 L/min and was admitted to the ICU.
He had history of HIV infection for over 20 years, regularly treating with etravirine, dolutegravir, darunavir and ritonavir for highly active antiretroviral therapy (HAART). The last TCD4+ cell count was above 500/µL and the viral load was undetectable for more than 5 years. He also had previous diagnosis of systemic arterial hypertension (SAH) and no history of diabetes mellitus or smoking.
On the day of admission, a nasopharyngeal swab was collected, and the RT-PCR for SARS-CoV-2 resulted positive. The virus panel for others agents was negative.
A chest computed tomography (CT) scan on admision (Figure 1-A) showed multiple ground-glass opacities, affecting all pulmonary lobes with predominantly peripheral distribution, associated with consolidation on lower lobes, with accented pulmonary involvement (> 50%). Empirical broad-spectrum antimicrobial therapy with ceftriaxone and azithromycin was started, the HAART was maintained and enoxaparin was prescribed (40mg/day).
The laboratorial exams revealed high percentage of white blood cell, a normal neutrophil count 6,410/mm3 (normal range: 1,700-7,000/mm3), a normal percentage lymphocyte count 1,050/mm3 (normal range: 900-2,900/mm3). There were elevated blood levels of C-reactive protein (PCR) 34,17 mg/dL (normal range: 0-5 mg/dL), D-dimer 8,469 ng/mL (normal range: < 0.5 ng/mL), and Lactic Dehydrogenase (LDH) 592 U/L (normal range: 240-480 U/L). The viral load was undetectable, and the CD4 cell count was 876 cell/mm3 (normal range: 404-1,612 cell/mm3), CD8 cell count was 876 cell/mm3 (normal range: 229-1,129 cell/mm³).
On March 22, endotracheal intubation was performed and the patient underwent mechanical ventilation with FIO2 60%, PEEP 8 mmHg and pressure support 20 mmHg. Blood gas analysis revealed pH 7.32 (normal range: 7.35-7.45), pO2 116 mmHg (normal range: 30-50 mmHg), pCO2 38 mmHg (normal range: 35-45 mmHg) and SatO2 98% (normal range: 94-100%). Hydroxychloroquine (HCQ), Azithromycin and Ceftriaxone were prescribed besides previous use of Etravirine, Dolutegravir, Darunavir and Ritonavir for HIV as maintenance treatment. On March 27, the use of Azithromycin and HCQ was interrupted and a Sulfamethoxazole-Trimetroprim in a prophylactic dose (800/160 mg/day) was initiated, due to TCD4+ cells count = 92 µ/L.
On March 29, cultures identified Staphylococcus epidermidis (central venous catheter blood), Staphylococcus hominis (central venous catheter blood) and Candida dubliniensis in the tracheal secretion and Meropenem, Linezolid and Micafungin were incorporated to the treatment. HIV viral load remained undetectable during this period.
On March 29th, the creatinine level was 2.4 mg/dL (normal range: 0.7-1.3 mg/dL) and he presented low diuresis (700 mL/24 hours), revealing a worsening in kidney function, and continuos veno-venous hemodialysis (CVVHD) was initiated. On early April, the interleukin-6 (IL6) measurement was 79.3 pg/mL (reference value: 1.5 – 7 pg/mL). On April 3rd, the patient received to-cilizumab 8 mg/kg (600 mg) intravenously. One day after, was patient’s first day without fever since admission, and started to improve progressively.
On April 7th, tracheostomy was performed, and five days later, he presented an improvement on respiratory condition - CT done on April 15th showed a significant improvement on pulmonary involvement (Figure 1-B) and mechanical ventilation was no longer needed.
On April 15th, the patient was discharged from the ICU and seven days later the tracheostomy was removed. On May 1st the patient was discharged from the hospital, and no prescription was needed unless the use of his regular medications. Clinical chronologic outcome is showed on Figure 2.