An unprecedented public health emergency is unfolding worldwide with the coronavirus disease 2019 (COVID-19) pandemic.1 After COVID-19 emerged, concern was voiced regarding its impact on people living with HIV.2 Some of the factors that increase susceptibility to human immunodeficiency virus (HIV) are also relevant for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19.3,4 Certain comorbidities were stronger drivers of COVID-19 outcomes and were associated with an increased risk of death.5
Opportunistic infections (OIs) are a leading cause of mortality in patients with acquired immunodeficiency syndrome (AIDS). Worldwide, tuberculosis (TB) is the predominant cause of death from an infectious disease, causing more deaths than HIV/AIDS. However, the HIV pandemic has worsened the situation not only by leading to the resurgence of TB but also by suppressing the host immune system, which provides an opportunity for infection by non-TB mycobacteria (NTM).6
The most common NTM species that causes disseminated infections in patients with HIV/AIDS is Mycobacterium avium complex (MAC). HIV patients with disseminated MAC infection are at high risk of developing complications and have a higher mortality risk, thus necessitating more active clinical management.7 M. avium is one of the main causes of NTM infection-associated morbidity and mortality in HIV/AIDS patients.8 MAC infections have clinical symptoms similar to active TB infections and are therefore easily mistaken for TB.
Candidiasis are commensal fungi of the oral mucosa often found in immunocompromised patients and are potential pathogens that can cause an OI. In HIV-1 and TB co-infected patients, oral candidiasis (OC) is found with a prevalence of 35%, and in HIV-1 patients with OC, there is a 2.4 times higher odds of having TB.9
In this report, we retrospectively describe a 23-year-old woman who was diagnosed with HIV 17 years prior. This patient had concurrent SARS-CoV-2, MAC, and OC infections. We present the diagnosis and management of these infections that allowed the patient’s recovery.
Case Presentation
The patient was a 23-year-old woman who had been diagnosed with HIV 17 years prior and had since received standard antiretroviral therapy (ART). Notably, she had switched from first line to simplified dual regimen (abacavir-lamivudine-efavirenz to lamivudine-dolutegravir) due to adverse events. She was diagnosed with TB five months prior, when her sputum smear was positive for acid-fast bacilli and the sputum culture subsequently grew TB. She was treated with rifampin, isoniazid, ethambutol, and pyrazinamide. According to “Chinese Guidelines for HIV/AIDS Diagnosis and Treatment”,10 when she was diagnosed with SARS-CoV-2 infection, she was in the AIDS stage due to poor adherence to antiretroviral medications with an HIV load of <100 viral copies/mL and a CD4+ T-cell count of 7 cells/µL.
On hospital day 1, the patient had a positive PCR test for SARS-CoV-2 in a hospital screening. She was referred to a local hospital with constitutional symptoms, including intermittent fever with chills. She had no cough or expectoration but was diagnosed with anemia and TB 5 months prior. There were no retrievable previous trends to compare.
On hospital day 6, the patient was transferred to the Southern Hospital of Zhengzhou First People’s Hospital. She had fever and chills, her temperature was 39.0°C at admission, and her SPO2 was 100% (without oxygen inhalation). She had density shadows in both lungs but had no respiratory distress and had normal oxygen saturation. The patient was found to have normochromic anemia with a hemoglobin level of 85 g/L. Additional blood test results are presented in Table 1. TB and COVID-19 were managed with azithromycin, moxifloxacin, isoniazid, rifabutin, and ethambutol, and ART was continued with lamivudine and dolutegravir. Anemia was treated by transfusion with suspended red blood cells. On hospital day 8, chest computed tomography (CT) scanning revealed substantial pulmonary lesions (Figure 1).
Table 1 Clinical Laboratory Results at Admission and Throughout the Clinical Course of Infection
On hospital day 13, the patient reported fever (temperature of up to 38.8°C), but no cough, sputum cough, chest tightness, or shortness of breath. Laboratory tests results are presented in Table 1. A diagnosis of disseminated MAC infection was made by two sputum cultures positive for MAC. Co-infection is a high-risk factor for the progression of COVID-19 to severe and the patient was treated with BRII-196+BRII198 monoclonal antibody therapy. MAC was managed with moxifloxacin, azithromycin, rifabutin and ethambutol, sulfamethoxazole given orally this compound also helps to prevent pneumocystis pneumonia (PCP). Thymalfasin was given to improve immunity, low molecular weight heparin calcium was given as an anticoagulant therapy, and the other treatments described above were continued. On hospital day 16, the chest CT scan showed a thin ground-glass density shadow in both lungs, but it was slightly smaller than in previous scans (Figure 2). Laboratory tests showed C-reactive protein (CRP) of 87.6 mg/L. Azithromycin and moxifloxacin were added to the treatment protocol for anti-infection treatment, and amikacin was used as an anti-MAC treatment.
Figure 2 CT scan showed a thin ground-glass density shadow in both lungs, but it was slightly smaller than in previous scans.
On hospital day 27, the patient had intermittent fever and pain in the left abdomen and the blood test results are presented in Table 1. Chest CT scanning was performed, which showed significant improvement of the pulmonary lesions (Figure 3). On hospital day 31, the patient received convalescent plasma therapy.
Figure 3 CT scanning showed significant improvement of the pulmonary lesions.
During days 35–48 of hospitalization, the patient had stable signs and did not have cough, fever, chest tightness, or shortness of breath. The treatments described above were continued.
During days 49–54 of hospitalization, the patient had scattered leukoplakia on the oral mucosa and received fluconazole injection as an antifungal treatment and a sodium bicarbonate gargle. She received a nebulized inhalation of 2 mL of sterilized water and was administered a twice-daily injection of recombinant human interferon α. On hospital day 54, a throat swab was submitted for fungal culture and returned a positive result for Candida albicans infection. The above treatments were continued.
On days 65–67 of hospitalization, two sequential PCR tests for SARS-CoV-2 returned negative results. Three consecutive days of examination showed negative results. The patient was discharged in accordance with the “Diagnosis and Treatment Plan for New Coronavirus Infected Pneumonia (Trial Seventh Edition)”.11
Discussion
A thorough history-taking and examination, as well as the appropriate use of clinical tools, are crucial for identifying concomitant OIs in immunosuppressed patients.
A longer course of COVID-19 has been reported in the setting of co-infection with HIV, particularly with low CD4 cell counts, low CD4+ levels and high levels of viral load influence the lethal progression of COVID-19.7,8,12 SARS-CoV-2 might damage lymphocytes, especially T lymphocytes, and the immune system was impaired during the period of disease.13 HIV-1 infection skewed the SARS-CoV-2 T cell response, HIV-1 mediated CD4+ T cell depletion associated with suboptimal T cell and humoral immune responses to SARS-CoV-2, and a decrease in the polyfunctional capacity of SARS CoV-2 specific CD4+ T cells was observed in COVID-19 patients.14 Our patient had multiple individual risk factors associated with prolonged viral shedding as well as a risk of severe SARS-CoV-2: advanced HIV with a low CD4 count. This maybe the reasons that over two months of intense treatment her CD4+ T cell and total lymphocyte counts remained very low, and her immune system did not improve.
The probability of an OI increases as the CD4+ T cell count declines, especially at counts below 200 cells/µL.15 This patient had switched from first line to simplified dual regimen (abacavir-lamivudine-efavirenz to lamivudine-dolutegravir) due to adverse event. She was in the AIDS stage due to poor adherence to antiretroviral medications and virological failure, with an HIV load of <100 viral copies/mL and a CD4+ T cell count maintained at <100 cells/µL, which may have contributed to the incidence of OIs. MAC are seen more commonly in patients with CD4+ T cell counts of <50 cells/µL.16 The risk of developing MAC infection increases in the presence of other concurrent infections such as TB.17 In AIDS patients, MAC infections often present clinically as disseminated MAC, with several weeks of early symptoms, such as prolonged fever, fatigue, weight loss, abdominal pain, diarrhea, and hepatosplenomegaly. MAC diagnoses are often delayed due to the nonspecific presentation of MAC pulmonary disease and radiological findings that overlap with other pulmonary diseases.18 Patients with risk factors and who meet the diagnostic criteria – which include clinical, radiological, and microbiological criteria – should be considered for treatment. In this case, disseminated MAC infection was diagnosed after two sputum MAC positive cultures over a period of two weeks, indicating that attention should be paid to the diagnosis. Oral candidiasis as a potential harbinger of T and B cell immunosuppression associated with viral infections and COVID-19 may be a risk factor for candidiasis.19 The practitioner should be aware of the importance of unexplained oral candidiasis associated with viral infections. PCP is a life-threatening opportunistic infection that can occur in immunodeficient individuals. The PCP mortality rate can reach 60% if the diagnosis is delayed.20 Early prevention reduces the incidence of PCP. In our case, PCP infection was prevented. This patient’s CD4+ T-cell count was below 200 cells/µL, and sulfamethoxazole was given orally to prevent PCP infection.
In terms of treatment, the use of monoclonal antibody therapy, ART, and broad-spectrum antibiotics is in line with recent literature for the treatment of COVID-19 in patients with impaired immune system functions. Neutralising monoclonal antibody therapies targeting SARS-CoV-2 accelerate reduction in viral loads and reduce the risk of disease progression for outpatient with mild COVID-19.14 Co-infection is a high-risk factor for the progression of COVID-19 to severe and the patient was treated with BRII196+BRII198 monoclonal antibody therapy. The only medication that has not been administered is steroids, which has an important reducing factor in lung injuries and was demonstrated to have better results regarding mortality rate in patients with moderate and severe COVID-19.21,22 However, at the time of the patient’s acquisition of severe immunosuppression and COVID-19, the main studies on the impact of steroids on COVID-19 mortality had not been published. Therefore, the patient did not receive steroids during hospitalization. Considering that our patient was diagnosed SARS-CoV-2 infection in a hospital screening, we speculated that in our patient, COVID-19 had existed for a long time before presentation.
Conclusion
There is a paucity of data on SARS-CoV-2 infection in people with HIV and low CD4 counts. Most studies have been retrospective cohort analyses of patients who are more likely to be virally suppressed and less likely to have CD4 counts of more than 200 cells per μL.9,23 In our cases illustrate that OIs is an important consideration in the presence of one in the setting of co-infection of advanced HIV disease and COVID-19. When treating immunocompromised individuals, some opportunistic infections, such as PCP, should be prevented in the presence of risk factors, these treatments may help reduce clinical symptoms and improve prognosis.
Ethics Statement
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The institutional approval was not required for the publication of the case details.
Funding
This work was supported by Henan Province COVID-19 Traditional Chinese Medicine Scientific Research Special Project (2022ZYFY02), the Nation Natural Science Foundation of China(U1904153), Science and Technology Research Project of Henan Province (222102310570) and Henan Province Special Project of Traditional Chinese Medicine Scientific research(2019AZB006,2019JDZX2096).
Disclosure
The authors declare that there are no competing interests in this work.
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14. Riou C, Stek C, Daroowala R, et al.; HIATUS consortium. Efficacy and safety of two neutralising monoclonal antibody therapies, sotrovimab and BRII-196 plus BRII-198, for adults hospitalised with COVID-19 (TICO): a randomised controlled trial. Lancet Infect Dis. 2022;22(5):622–635. doi:10.1016/s1473-3099(21)00751-9
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Skinstitut Holiday Gift Kits take the stress out of gifting
Toronto, October 31, 2024 – Beauty gifts are at the top of holiday wish lists this year, and Laser Clinics Canada, a leader in advanced beauty treatments and skincare, is taking the pressure out of seasonal shopping. Today, Laser Clincs Canada announces the arrival of its 2024 Holiday Gift Kits, courtesy of Skinstitut, the exclusive skincare line of Laser Clinics Group.
In time for the busy shopping season, the limited-edition Holiday Gifts Kits are available in Laser Clinics locations in the GTA and Ottawa. Clinics are conveniently located in popular shopping centers, including Hillcrest Mall, Square One, CF Sherway Gardens, Scarborough Town Centre, Rideau Centre, Union Station and CF Markville. These limited-edition Kits are available on a first come, first served basis.
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LONDON (AP) — Most people have accumulated a pile of data — selfies, emails, videos and more — on their social media and digital accounts over their lifetimes. What happens to it when we die?
It’s wise to draft a will spelling out who inherits your physical assets after you’re gone, but don’t forget to take care of your digital estate too. Friends and family might treasure files and posts you’ve left behind, but they could get lost in digital purgatory after you pass away unless you take some simple steps.
Here’s how you can prepare your digital life for your survivors:
Apple
The iPhone maker lets you nominate a “ legacy contact ” who can access your Apple account’s data after you die. The company says it’s a secure way to give trusted people access to photos, files and messages. To set it up you’ll need an Apple device with a fairly recent operating system — iPhones and iPads need iOS or iPadOS 15.2 and MacBooks needs macOS Monterey 12.1.
For iPhones, go to settings, tap Sign-in & Security and then Legacy Contact. You can name one or more people, and they don’t need an Apple ID or device.
You’ll have to share an access key with your contact. It can be a digital version sent electronically, or you can print a copy or save it as a screenshot or PDF.
Take note that there are some types of files you won’t be able to pass on — including digital rights-protected music, movies and passwords stored in Apple’s password manager. Legacy contacts can only access a deceased user’s account for three years before Apple deletes the account.
Google
Google takes a different approach with its Inactive Account Manager, which allows you to share your data with someone if it notices that you’ve stopped using your account.
When setting it up, you need to decide how long Google should wait — from three to 18 months — before considering your account inactive. Once that time is up, Google can notify up to 10 people.
You can write a message informing them you’ve stopped using the account, and, optionally, include a link to download your data. You can choose what types of data they can access — including emails, photos, calendar entries and YouTube videos.
There’s also an option to automatically delete your account after three months of inactivity, so your contacts will have to download any data before that deadline.
Facebook and Instagram
Some social media platforms can preserve accounts for people who have died so that friends and family can honor their memories.
When users of Facebook or Instagram die, parent company Meta says it can memorialize the account if it gets a “valid request” from a friend or family member. Requests can be submitted through an online form.
The social media company strongly recommends Facebook users add a legacy contact to look after their memorial accounts. Legacy contacts can do things like respond to new friend requests and update pinned posts, but they can’t read private messages or remove or alter previous posts. You can only choose one person, who also has to have a Facebook account.
You can also ask Facebook or Instagram to delete a deceased user’s account if you’re a close family member or an executor. You’ll need to send in documents like a death certificate.
TikTok
The video-sharing platform says that if a user has died, people can submit a request to memorialize the account through the settings menu. Go to the Report a Problem section, then Account and profile, then Manage account, where you can report a deceased user.
Once an account has been memorialized, it will be labeled “Remembering.” No one will be able to log into the account, which prevents anyone from editing the profile or using the account to post new content or send messages.
X
It’s not possible to nominate a legacy contact on Elon Musk’s social media site. But family members or an authorized person can submit a request to deactivate a deceased user’s account.
Passwords
Besides the major online services, you’ll probably have dozens if not hundreds of other digital accounts that your survivors might need to access. You could just write all your login credentials down in a notebook and put it somewhere safe. But making a physical copy presents its own vulnerabilities. What if you lose track of it? What if someone finds it?
Instead, consider a password manager that has an emergency access feature. Password managers are digital vaults that you can use to store all your credentials. Some, like Keeper,Bitwarden and NordPass, allow users to nominate one or more trusted contacts who can access their keys in case of an emergency such as a death.
But there are a few catches: Those contacts also need to use the same password manager and you might have to pay for the service.
___
Is there a tech challenge you need help figuring out? Write to us at onetechtip@ap.org with your questions.
The Canadian Paediatric Society says doctors should regularly screen children for reading difficulties and dyslexia, calling low literacy a “serious public health concern” that can increase the risk of other problems including anxiety, low self-esteem and behavioural issues, with lifelong consequences.
New guidance issued Wednesday says family doctors, nurses, pediatricians and other medical professionals who care for school-aged kids are in a unique position to help struggling readers access educational and specialty supports, noting that identifying problems early couldhelp kids sooner — when it’s more effective — as well as reveal other possible learning or developmental issues.
The 10 recommendations include regular screening for kids aged four to seven, especially if they belong to groups at higher risk of low literacy, including newcomers to Canada, racialized Canadians and Indigenous Peoples. The society says this can be done in a two-to-three-minute office-based assessment.
Other tips encourage doctors to look for conditions often seen among poor readers such as attention-deficit hyperactivity disorder; to advocate for early literacy training for pediatric and family medicine residents; to liaise with schools on behalf of families seeking help; and to push provincial and territorial education ministries to integrate evidence-based phonics instruction into curriculums, starting in kindergarten.
Dr. Scott McLeod, one of the authors and chair of the society’s mental health and developmental disabilities committee, said a key goal is to catch kids who may be falling through the cracks and to better connect families to resources, including quicker targeted help from schools.
“Collaboration in this area is so key because we need to move away from the silos of: everything educational must exist within the educational portfolio,” McLeod said in an interview from Calgary, where he is a developmental pediatrician at Alberta Children’s Hospital.
“Reading, yes, it’s education, but it’s also health because we know that literacy impacts health. So I think that a statement like this opens the window to say: Yes, parents can come to their health-care provider to get advice, get recommendations, hopefully start a collaboration with school teachers.”
McLeod noted that pediatricians already look for signs of low literacy in young children by way of a commonly used tool known as the Rourke Baby Record, which offers a checklist of key topics, such as nutrition and developmental benchmarks, to cover in a well-child appointment.
But he said questions about reading could be “a standing item” in checkups and he hoped the society’s statement to medical professionals who care for children “enhances their confidence in being a strong advocate for the child” while spurring partnerships with others involved in a child’s life such as teachers and psychologists.
The guidance said pediatricians also play a key role in detecting and monitoring conditions that often coexist with difficulty reading such as attention-deficit hyperactivity disorder, but McLeod noted that getting such specific diagnoses typically involves a referral to a specialist, during which time a child continues to struggle.
He also acknowledged that some schools can be slow to act without a specific diagnosis from a specialist, and even then a child may end up on a wait list for school interventions.
“Evidence-based reading instruction shouldn’t have to wait for some of that access to specialized assessments to occur,” he said.
“My hope is that (by) having an existing statement or document written by the Canadian Paediatric Society … we’re able to skip a few steps or have some of the early interventions present,” he said.
McLeod added that obtaining specific assessments from medical specialists is “definitely beneficial and advantageous” to know where a child is at, “but having that sort of clear, thorough assessment shouldn’t be a barrier to intervention starting.”
McLeod said the society was partly spurred to act by 2022’s “Right to Read Inquiry Report” from the Ontario Human Rights Commission, which made 157 recommendations to address inequities related to reading instruction in that province.
He called the new guidelines “a big reminder” to pediatric providers, family doctors, school teachers and psychologists of the importance of literacy.
“Early identification of reading difficulty can truly change the trajectory of a child’s life.”
This report by The Canadian Press was first published Oct. 23, 2024.
