A 37-year-old nulliparous woman with a past medical history of a recent diagnosis of HIV infection not on anti-retroviral therapy was admitted at the Mulago National Referral Hospital (MNRH) COVID-19 Treatment Unit (CTU), Uganda with a 3-day history of worsening cough and difficulty in breathing. She had had a productive cough with mucoid sputum accompanied by evening fevers and weight loss of a 2-month duration. On the referral note, there was also a documented history of anosmia, high-grade intermittent fevers, headaches, altered mentation, an episode of loss of consciousness and myalgias for a duration of 5 days. Four days prior to referral to MNRH CTU from a general hospital, her nasopharyngeal swab for SARS-CoV-2 was positive on both reverse transcriptase-polymerase chain reaction (RT-PCR) and rapid antigen tests. She had tested positive for HIV infection 8 days prior to admission and was not undergoing anti-retroviral therapy or cotrimoxazole prophylaxis.
On presentation (day 0), she was critically ill, febrile with an axillary temperature of 38.5  C, a tachycardia of 168 beats per minute, tachypnoea of 32 breaths per minute, random blood sugar of 8.7 mmol/L, blood pressure of 132/76 mmHg and was hypoxic with a saturation ranging between 85-90% on 5 liters per minute via a nasal prong. Respiratory examination revealed nasal flaring, with intercostal recessions. There were widespread, bilateral, coarse crepitations. She was restless with a Glasgow coma scale of 8/15 (eye opening 3, best verbal response 2 and best motor response 3). Her neck was stiff, with a positive Kernig's sign. Other systems were unremarkable.
Her serum and cerebrospinal fluid cryptococcal antigen (CrAg) (Immy Inc., Norman, OK) tests were positive (Figure 1). A blood smear was negative for Plasmodium and other haemoparasites. Complete blood count revealed a white blood cell count of 11.8 x 103/microL, with a neutrophilia of 10.8 (91.6%) and a lymphopenia of 0.53 (4.5%). She had a microcytic anemia with hemoglobin level of 8.5 g/dl and mean corpuscular volume of 67fL. Her platelet levels were normal at 300 x103/microL. Renal and liver biochemistry were within limits. Her blood group was B rhesus D positive. The urine lipoarabinomannan (LAM) was positive (Grade II) (Figure 1). Chest radiography revealed features of miliary tuberculosis with background ground glass opacities (Figure 2). Unenhanced computed tomography of the brain demonstrated a right sided large geographic area of hypodensity (19-25 HU) involving the right frontoparietotemporal cortex in the territory of the right middle cerebral artery with an associated hyperdense middle cerebral artery sign (Figure 3A and B). Sputum and blood samples were taken off for GeneXpert and cultures, respectively. The GeneXpert was positive without rifampicin resistance. Anaerobic, aerobic, fungal and mycobacterial cultures were negative. CD4+ T-cell count was 32 cell/microliter and HIV RNA viral load was unknown. Her urine human chorionic gonadotrophin was negative.
A diagnosis of severe COVID-19 in the background of advanced HIV infection with complications of CM, disseminated tuberculosis and microcytic anemia was made. She was initiated on intravenous dexamethasone at a dose of 6 mg once daily, subcutaneous enoxaparin 60 mg once daily, intravenous paracetamol 1 g three times a day, cotrimoxazole 960 mg once daily, oral fluconazole 1200 mg once daily and intravenous piperacillin/tazobactam 4.5 g three times daily. Also, 300 mg of aspirin was administered as a STAT dose followed by 75 mg once daily. Anti-TB drugs were not available at the CTU and were being sought from the TB treatment unit. On day +1, a nasogastric tube was passed for feeding and urethral catheter was passed to monitor urine output.
Despite an escalation of oxygen delivery via non-rebreather mask (at 15 L per minute), and later high-flow nasal cannula (at 50 liters per minute), the patient continued to deteriorate with an increasing oxygen requirement and worsening hypoxemia. She passed on within 36 hours of hospitalization, as we were looking for intensive care unit space for assisted ventilation.