A 55-year-old male known HIV-positive patient on antiretroviral therapy (TDF 300 mg + FTC 200 mg + EFV 600 mg) for the last 3 years was referred from Gidda Ayana District Hospital on May 26, 2021 to Wollega University referral hospital. Upon arrival to the emergency department, he complained of shortness of breath of five days' duration, which began suddenly, and became more and more persistent, associated with productive cough, high-grade fever, malaise, and severe headache. In addition, he had a loss of appetite, weight loss, chest pain, night sweats, and fatigue. Moreover, he had a history of bloody sputum one month prior to the current complaint. He has tolerated well but had poor adherence to his ART medication and had no previous history of alcohol consumption and other illicit drugs. He has reported receiving cotrimoxazole prophylaxis for three years, but often missed some doses. His current CD4 count was 266 cells/mm3, and HIV-1 RNA level was 9000 copies/mL.
Upon physical examination at presentation, the patient looked acutely sick, and blood pressure was measured at 110/60 mmHg, a body temperature of 39.3 C, and pulse rate of 112 beats per minute, classed as tachycardia. His respiratory rate was 38/minute, and his oxygen saturation was 87% on room air. His breathing was shallow, rapid, and used respiratory accessory muscles. There was dullness over the left lower lobe. Breathing sounds were vesicular on the right side but markedly reduced at the base. There was coarse crepitation over the left upper and lower lobes. He was conscious and oriented. Immediately the patient was admitted as a medical emergency and put on intranasal oxygen.
Necessary laboratory investigations were performed. Accordingly, random blood sugar was 110 mg/dL, complete blood count with differential revealed only leukocytosis (15.2 x 103/L) with lymphocyte predominance, erythrocyte sedimentation rate (ESR) of 86 mm/hour; blood film (BF) showed no hemoparasite, serum creatinine was 0.9 mg/dL, and liver function test showed no abnormal value. Chest X-ray showed perihilar patchy opacities (Figure 1).
Gene Expert test was done from sputum and was positive for TB (no rifampin resistance), and nasopharyngeal sample for SARS CoV-2 PCR was positive. On his 2nd day of admission, he was transferred to a COVID-19 dedicated treatment center located in the same hospital with the diagnosis of severe COVID-19, pulmonary TB, and WHO stage-3 RVI.
During his stay, oxygen supplementation for an SpO2 target >=92-96% was provided with 6-10 L O2 via a nasal cannula. Conservative IV fluid management with empiric antimicrobials for possible bacterial infection was started with cefepime 2 g IV TID for 3 days then changed to an oral antibiotic. In addition, dexamethasone 6 mg once per day IV was given with close monitoring of vital signs, work of breathing, and mental status. Anti-TB drugs were initiated with RHZE (rifampicin, isoniazid, pyrazinamide, and ethambutol) at the intensive phase on the 3rd day of admission. Highly active antiretroviral therapy was continued with the same regimen he was taking before presentation to the hospital.
On his 6th day of admission, the patient became afebrile and started to maintain his oxygen saturation >94% with room air. The patient's general condition also improved. Follow-up RT-PCR test for COVID-19 was done, and the results were negative. On June 6, 2021 the patient was discharged from hospital after 10 days of hospital stay, and a follow-up appointment at the ART and TB clinic within two weeks was given.