COVID-19 Complications in a Newly Diagnosed HIV Patient: A Case of Multiple Herpesvirus Reactivation and HLH Post-ART Initiation

Background

The presentation of SARS-CoV-2 infection varies widely, from asymptomatic disease to severe respiratory illness with end-organ damage, including acute kidney injury, liver failure, cardiac injury, and acute respiratory distress syndrome [1,2]. People living with human immunodeficiency virus (HIV) may have a higher risk of acquiring SARS-CoV-2, and have a higher risk of hospitalization and death, particularly for those not virally suppressed or with CD4 count less than 200 cells/mm [3,4]. SARS-CoV-2 induces excessive production of pro-inflammatory cytokines and immune dysregulation, including reduction in lymphocytes, with greater reduction of T-cell counts in severe cases [2,5]. In patients co-infected with HIV, SARS-CoV-2 appears to augment the exhaustion of T-cells that occurs as HIV progresses, particularly in patients not receiving antiretroviral therapy (ART) [6,7], which is a potential mechanism for the observed increased risk of hospitalization and death. However, HIV-positive patients can also exhibit exaggerated inflammatory response after initiation of ART, leading to immune reconstitution inflammatory syndrome (IRIS) as the HIV viral load decreases and CD4+ T-lymphocytes increase [8,9], and little is known about the risks of initiating ART in the setting of COVID-19. Furthermore, IRIS has been associated with a variety of opportunistic infections [10] and COVID-19 has been linked to the development of Epstein-Barr virus (EBV), Cytomegalovirus (CMV), and Human Herpesvirus-6 (HHV-6) reactivation in critically-ill patients[11]. IRIS and hyperinflammatory changes in severe SARS-CoV-2 infection have similar features to some forms of hemophagocytic lymphohistiocytosis (HLH) [8,12–15] and some have even postulated that the hyperinflammatory state in severe COVID-19 could be a form of HLH [16].

HLH is a life-threating condition characterized by excessive immune activation and systemic inflammation that can lead to multi-organ failure [17,18]. The end-organ damage seen in HLH is due to overproduction of interferon-γ by activated T-lymphocytes, which in turn activates CD8+ T-cells, macrophages, and histiocytes, resulting in secretion of pro-inflammatory cytokines and infiltration of multiple tissues [19–21]. Macrophage activation syndrome (MAS), a form of HLH, is a complication of autoimmune diseases such as systemic onset juvenile idiopathic arthritis and juvenile systemic lupus erythematous [18,22]. HLH is divided into inherited or familial HLH, which is caused by genetic mutation presenting during childhood [23] and acquired HLH (including MAS), which is associated with immune dysregulation such as autoimmune disease, malignancy or infection [24–26]. HLH is associated with infectious processes including EBV, CMV, parvovirus, herpes simplex virus-2, and human herpesvirus-8 (HHV-8), as well as HIV with and without opportunistic infections [27,28]. EBV, HHV-8, and histoplasmosis are the most frequently described co-occurring pathogens with HIV in HLH [29]. In a review of HLH and HIV, 19% of patients were started on ART shortly before developing HLH, and IRIS was considered in the differential diagnosis, as features can overlap [29]. It has been suggested that a form of secondary HLH can be triggered by IRIS after initiation of ART through HIV-related defects in NK-cells and T-cell cytotoxicity combined with increased production of cytokines related to opportunistic infections and ART initiation [30].

Herein, we describe a case of SARS-CoV-2 infection in a patient with previously undiagnosed HIV and Kaposi sarcoma who developed fatal HLH and herpesvirus reactivation after initiation of ART.

Case Report

A 45-year-old man with no known past medical history presented with dyspnea and dry cough for 2 weeks. He had mild exertional shortness of breath that progressively worsened. In the Emergency Department, initial vital signs were temperature 36.7°C, heart rate 96 beats per minute, blood pressure 130/77 mmHg, respiratory rate 21 breaths per minute, and oxygen saturation 85% on room air. A nasopharyngeal swab sent for Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV real-time reverse transcriptase-polymerase chain reaction testing was positive for SARS-CoV-2, and he was admitted for acute hypoxic respiratory failure secondary to COVID-19. A timeline of the patient’s clinical course, diagnostic workup, and treatment is shown in Figure 1.

The initial physical exam was remarkable for an ill-appearing man using accessory muscles of respiration on a nonre-breather mask. Lung auscultation revealed rales at lower bases. A skin examination was notable for numerous violaceous and hyper-pigmented, non-blanching maculopapular lesions on his legs and abdomen (Figure 2). A complete blood cell count was notable for total white blood cell count of 6.73×103 cells/µL (reference range 4.80–10.80×103 cells/µL) with decreased total lymphocyte count of 810 cells/µL (reference range 1000–49 000 cells/µL), hemoglobin level of 9.4 g/dL (reference range 14.0–18.0 g/dL), and normal platelet count of 345×103/µL (reference range 150–450×103 cells/µL). Creatinine was elevated to 1.63 mg/dL (reference range 0.50–1.30 mg/L) and liver function tests were notable for an elevated alkaline phosphatase to 140U/L (reference range 30–120 U/L). D-dimer was elevated to 378 ng/mL (reference range 0–243 ng/mL) and lactate dehydrogenase was elevated to 409 U/L (reference range 60–250 U/L). Triglyceride level was mildly elevated to 164 mg/dL (reference range 30–150 mg/dL). Chest radiography showed bilateral prominence of the interstitium and alveolar opacities (Figure 3). The patient was treated with remdesivir 200 mg i.v. once followed by 100 mg i.v. daily for a total of 5 days, dexamethasone 6 mg i.v. daily for 10 days, and 1 unit of convalescent plasma for SARS-CoV2 infection, as per National Institute of Health guidelines at the time of admission [31].

On hospital day 2, HIV-1/2 antibody testing (BioRad Geenius Immunoassay) was performed and was reactive. His absolute CD4 count was 18 cells/µL (reference range 489–1457 cells/µL) and absolute CD8 count was 590 cells/µL (reference range 142–740 cells/µL); trimethoprim-sulfamethoxazole was initiated for Pneumocystis jirovecii (PJP) prophylaxis and ART was offered but deferred based on patient preference. On hospital day 3, additional testing revealed HIV RNA viral load (Hologic Panther) was 1 921 736 copies/mL, Toxoplasma gondii immunoglobulin G (IgG) antibody was negative, Varicella IgG was positive, serum CMV DNA PCR (Viracor) was positive with value of 11 700 IU/mL, QuantiFERON plus tuberculosis interferon gamma assay was indeterminate, Treponema pallidum antibody screen was negative, and antibody screening for active hepatitis A, B, and C was negative. CMV and EBV serologies to assess evidence of prior infection were recommended but not performed. A punch biopsy of one of the hyper-pigmented lesions noted on admission showed irregular-shaped, branching, and slit-like channels containing erythrocytes and lined by spindle cells, a sparse lymphohistiocytic infiltrate with occasional plasma cells, negative PAS stain for fungal elements, and lesional cells immunoreactive for HHV-8, consistent with the patch/plaque stage of Kaposi sarcoma (Figure 4). On hospital day 4, he developed a fever to 38.7°C, and endorsed new blood-streaked sputum with increasing oxygen requirement from 3 L by nasal cannula to 4 L by nasal cannula. Chest radiography showed progression of severe diffuse bilateral airspace consolidations, which were worse than in the exam performed on the day of admission, as well as new bilateral pleural effusions (Figure 5). Three sputum specimens for acid-fast bacilli stain and culture were performed 8 hours apart; stains were negative, and 1 of 3 samples ultimately grew Mycobacterium avium complex. After consideration and discussion of risks and benefits, the patient agreed to initiate ART with dolutegravir, emtricitabine, and tenofovir alafenamide on hospital day 5.

The patient’s symptoms, oxygen requirements, and vital signs remained stable until hospital day 10, when he developed worsening hypoxia requiring 15 L oxygen via a non-rebreather mask. At that time, serum cryptococcal antigen was negative, but beta-D-glucan was elevated to >500 pg/mL. The patient was treated for suspected PJP with trimethoprim-sulfamethoxazole and dexamethasone (the dose was increased to 6 mg i.v. q12h for 5 days, then tapered), and empiric voriconazole was initiated for potential fungal infection, including Aspergillus sp., based on known risk of superinfection in patients with COVID-19 pneumonia. Respiratory specimens for bacterial culture ultimately grew only normal respiratory flora, fungal culture grew Candida albicans, KOH/calcofluor white stain was negative for organisms including PJP, serum galactomannan was below the limit of detection, and urine Histoplasma antigen was negative. PJP PCR was suggested but not collected. Cytology was not performed. His respiratory failure did not respond to high-dose steroids, empiric voriconazole for fungal disease, and treatment for suspected PJP, ultimately requiring intubation.

On hospital day 23, the patient developed fever to 38.1°C and hypotension requiring vasopressors. Blood and urine cultures grew Escherichia coli susceptible to all agents except ampicillin-sulbactam and trimethoprim-sulfamethoxazole, and the patient was treated with ceftriaxone. PJP and antifungal treatments were discontinued based upon negative diagnostic studies, and steroid therapy was changed to stress-dose dexamethasone 20 mg i.v. daily for 3 days in the setting of septic shock. Total CD4 count repeat was 7 cells/µL. On hospital day 25, he had sudden onset of renal failure (creatinine 3.19 mg/dL) with acidosis (pH 7.14), and hyperkalemia (potassium 6.4 mmol/L) requiring initiation of hemodialysis. He also developed thrombocytopenia (platelet count 130×103 cells/µL), worsening anemia (hemoglobin 9.9×103 cells/µL), and lymphopenia (total lymphocyte count 0.27×103 cells/µL). A manual blood smear did not show schistocytes or hemophagocytosis, but revealed 4% bands and some metamyelocytes and myelocytes. Dexamethasone was decreased to 6 mg i.v. daily.

On hospital day 28, the patient was persistently febrile up to 38.7°C, with hypotension, tachycardia, and persistent hyper-capnic respiratory failure, with rising oxygen requirements, but sputum cultures and blood cultures for bacteria, acid-fast bacteria, and fungi were negative for growth, and serum cryptococcal antigen, urine Histoplasma antigen, and Strongyloides IgG antibodies were negative. Chest radiographs showed continued presence of bilateral diffuse airspace disease (Figure 6). Dexamethasone 6 mg i.v. daily was continued for acute respiratory distress syndrome related to COVID-19. Two repeat manual blood smears did not show schistocytes or hemophagocytosis. His hematologic abnormalities progressed over the next 72 h, with total white blood cell count 3.73×103/µL, hemoglobin 9.1 g/dL, and platelet level 20×103/µL. CMV DNA PCR (Viracor) was repeated and detectable at 1.80×107 IU/mL, and EBV DNA PCR (Viracor) was detectable at 1400 IU/mL. Ganciclovir and voriconazole were started and antibacterial treatments were broadened to vancomycin and meropenem empirically. Further workup revealed fibrinogen was elevated to >700 mg/dL (reference range 322–496 mg/dL), D-dimer was elevated to 2643 ng/mL (reference range 0–243 ng/mL), and ferritin was elevated to 21 694 ng/mL (reference 30–400 ng/mL), consistent with a hyperinflammatory state. Triglycerides were 389 mg/dL (reference range 30–150 mg/dL), and transaminases were elevated (aspartate aminotransferase [AST] was 797 U/L and alanine transaminase [ALT] level was 170 U/L); ultrasound of the abdomen revealed hepatomegaly. Interleukin-6 level (LabCorp) was elevated at 50.3 pg/mL (reference range 0.0–13.0 pg/mL) and interleukin-2 receptor/soluble CD25 (ARUP) was elevated at 4067.3 pg/mL (reference range 175.3–858.2 pg/mL), raising a suspicion for HLH. Unfortunately, he was too unstable to undergo bone marrow biopsy, and by the hematology service felt he was a poor candidate for chemotherapeutic agents for HLH.

On hospital day 32, the patient developed a right-sided pneumothorax requiring chest tube placement (Figure 7). The following day, he continued to show hemodynamic decline, refractory hypoxemia, and multi-organ failure. Despite maximal supportive therapy, patient’s condition failed to improve and he died on hospital day 33.

Discussion

This case of HLH in a severely immunocompromised patient with advanced HIV and SARS-CoV-2 co-infection highlights the overlap in features, difficulty in distinguishing HLH from hyperinflammatory changes associated with severe COVID-19, and uncertainty regarding how immune dysregulation in HIV might contribute to COVID-19 complications. The risks of initiating ART in the setting of COVID-19 are unknown, but include potential worsening of a hyperinflammatory state in some patients.

HLH-2004 criteria for diagnosis of HLH include fever, splenomegaly, at least 2 lineages of cytopenia, hypertriglyceridemia (fasting, >265 mg/dL) and/or hypofibrinogenemia (<150 mg/dL), hyperferritinemia (>500 ng/mL), soluble IL-2 receptor level (sCD25) elevation, and low/absent NK cell functional assays [32]. Diagnosis is made if 5 out of 8 criteria are fulfilled. The H-score (reactive hemophagocytic syndrome diagnosing score) was developed to predict the probability of HLH and consists of variables including cytopenia, ferritin, triglyceride, fibrinogen, AST, fever, and hepatosplenomegaly [33]. For each variable, a weighted number of points are delegated to calculate the score associated with probability of HLH. Making the diagnosis of HLH with concomitant COVID-19 can be difficult due to significant overlap between inflammatory changes and end-organ damage in both conditions, and variation in clinical features [34]. It has been noted that the H-score alone in the absence of further studies (such as bone marrow biopsy) lacks sensitivity in the setting of COVID-19 and can result in missed diagnoses of HLH [13,35]. As a result, further studies examining the role of other biomarkers (NK cell activity, soluble IL-2 receptor, and soluble CD163) in the diagnosis of COVID-19-associated HLH have been recommended [36]. The observation that patients with COVID-19 in ICU settings are more likely to develop EBV, CMV, and HHV-6 reactivation in comparison to other critically-ill patients in the ICU supports the idea that HLH may be more common in this population than appreciated [11]. In the present case, the patient met 5 criteria per HLH-2004 criteria: fever, hyperferritinemia, cytopenias, hepatomegaly, and hyper-triglyceridemia. Additionally, he had a score of 221 on H-score associated with immunosuppression, fever, hepatomegaly, 3 lineages of cytopenia (lymphocytopenia, anemia and thrombocytopenia), triglyceride of 389 mg/dL, ferritin of 21 694 ng/mL, fibrinogen greater than 250 mg/dL, and AST of 563 U/L, giving a 96–98% probability of the syndrome. The apparent reactivation of numerous herpesviruses (HHV-8, CMV, EBV), and the patient’s underlying HIV in this case would also seemingly increase the risk and likelihood of HLH as the cause of his inflammatory syndrome. Unfortunately, we were not able to obtain a bone marrow biopsy for any hemophagocytosis features, as the patient was hemodynamically unstable; however, biopsy is not required for diagnosis of HLH.

In general, treatment of HLH depends on the underlying cause; however, corticosteroids are commonly used to halt the hyper-activation of the immune system, and some cases etoposide is used for its cytolytic effect on dividing T-cells, suppressing cytokine activity [37,38]. Some of the same immune modulating agents recommended for COVID-19 treatment are also used for HLH [31]. Similarly, corticosteroids are used to treat more severe cases of IRIS [39]. In this case, the patient received dexamethasone but did not clinically respond and was deemed too high risk for other therapeutic agents. It is unlikely that the patient’s deterioration was due to IRIS alone, since he received dexamethasone without improvement and his T-cell lymphocytes did not increase. Nevertheless, it is unclear if initiation of antiretroviral therapy contributed to his worsening hyperinflammatory state, and whether delay in starting ART in patients with COVID-19 who have advanced HIV is prudent. Indeed, there is a shift in cytokine production from a Th-2 to a Th-1 profile after initiation of ART, with increases in interleukin-2 and interferon-γ, as well as stimulation of monocytes and macrophages, resulting in production of TNFα and IL-6, which are also implicated in HLH and severe COVID-19 [5,9,14,19,40]

Only 1 other report exists in the literature of a treatment-naïve patient with newly diagnosed HIV and SARS-CoV-2 co-infection who was started on ART [41]. That patient had PJP and CMV pneumonitis, decompensated after initiation of ART, and ultimately died. The authors attributed the decompensation to possible IRIS; however, that patient did not have a diagnosis of HLH.

Limitations of this case report include overlap between HLH features and other inflammatory conditions, lack of PJP PCR or cytology results to further investigate this diagnosis, lack of CMV and EBV serology to confirm reactivation rather than primary infection, risk of falsely elevated beta-D-glucan after receipt of convalescent plasma, and the potential for bone marrow suppression related to trimethoprim-sulfamethoxazole as an additional contributing factor to the patient’s hemato-logic abnormalities and renal failure prior to discontinuation.

Conclusions

The overlap of hyperinflammatory changes in severe COVID-19, HLH, and IRIS raise the alarm for risk of clinical deterioration after early ART initiation in the setting of SARS-CoV-2 and HIV co-infection, particularly in patients with concurrent opportunistic infections or severe features of COVID-19. Additional research is needed to determine the risk factors and optimal timing of ART in this patient population.