IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME AFTER USE OF ANTI-RETROVIRAL THERAPY IN COVID-19

ABSTRACT

TOPIC Chest Infections TYPE Global Case Reports INTRODUCTION: COVID-19 is still an emerging topic and co-existence in HIV patients presents its unique challenge. These patients can range from elite controllers to Acquired immunodeficiency syndrome (T cell CD4 < 200). Throughout our management, we noticed certain trends in our population. Those patients with CD4 T cell < 200 were rarely admitted to hospital with severe cases of COVID-19, requiring if anything minimal oxygen requirements. However, HIV patients who were admitted did not fare well after initiating their anti-retroviral therapy (ART) therapy during index hospitalization. We describe two such cases one in which ART was maintained and one in which ART was help with different outcomes. CASE PRESENTATION Both patients on admission were admitted for progressive dyspnea with COVID PCR positive, started on ART therapy, given a 10-day course of Dexamethasone 6mg and 5 doses of Remdisivir.Case 1 - 55year old Hispanic male with a history of non-compliance on Triumeq (CD4 count of 34), lymphoma in remission after chemotherapy, and sulfa allergy. On admission he was started on Triumeq, Azithromycin, Clindamycin, Primaquine. Over next 3 days he experienced progressive hypoxia and worsening chest imaging eventually requiring mechanical ventilation.Case 2 - 66year old female non-compliant on ART, and polysubstance abuse. She was also noted to have MSSA pneumonia. She was started on Emricitabine, Tenofovir, Ritonavir, and Atazanorvir. Within 48 hours of ART initiation her oxygen requirement increased. At this time, her antiretrovirals were stopped and started on Solumedrol 40mg twice daily for suspected IRIS. Her respiratory status improved and her oxygen requirements were back to baseline. Upon restarting ART 2 weeks post treatment for IRIS, patient again required an increase in oxygen supplementation. ART was held for an extended period while maintaining opportunistic infection prophylaxis. DISCUSSION: We pose this discussion for the community, as COVID-19 pathophysiology has been hypothesized to be an inflammatory response mitigated by Interleukins and Interferon-gamma, released by CD4 and CD8 T cells {3} Theoretically those with lower CD4 T cells, such as those with AIDs, should produce a lesser inflammatory response;and therefore, be less symptomatic. IRIS is typically determined from clinical context and is seen more frequently in those with CD4 < 100. {1} Treatment is typically steroids with a prolonged taper, with an ongoing discussion on whether ART should be held. {4} CONCLUSIONS: Currently there are no guidelines regarding utilization of ART in HIV patients infected with COVID;which leads to following questions of whether ART be held transiently until the COVID-19 pneumonia has been sufficiently treated? When should ART be restarted in these patients? If a patient's condition is deteriorating, should the patient's ART be held and started on opportunistic infection prophylaxis? REFERENCE #1 Bosamiya, S.S. The immune reconstitution inflammatory syndrome (2011) 56(5) 476-9, Indian J Dermatology. doi 10.4103/0019-5154.87114 REFERENCE #2 Brown, L.B, Spinelli, M.A., and Gandhi, M. The interplay between HIV and COVID-19 summary of the data and responses to date. (2021) 16(1) 63-73, Current opinion of HIV and AIDs. REFERENCE #3 Kalfaoglu, B., Almeida-Santos, J., Tye, C.A., Satou, Y., and Ono, M. T cell dysregulation in COVID-19 (2020) 29(530) 204-210, Biochem Biophys Res Commun. doi 10.1016/j.bbrc.2020.10.079 DISCLOSURES No relevant relationships by Obed Adarkwah, source=Web Response no disclosure on file for Anjali Bakshi;No relevant relationships by Louis Gerolemou, source=Web Response No relevant relationships by Aneeta Kumari, source=Web Response No relevant relationships by Nabil Mesiha, source=Web Response No relevant relationships by Steven Miller, source=Web Response No relevant relationships by Kunal Nangrani, source=Web Response No relevant relationships by Jose Orsini, source=Web Response No relevant relationships by Gaurav Parhar, source=We Response no disclosure on file for Dhruv Patel;No relevant relationships by Jason Ravidas, source=Web Response No relevant relationships by jad sargi, source=Web Response No relevant relationships by Viswanath Vasudevan, source=Web Response No relevant relationships by Kiran Zaman, source=Web Response No relevant relationships by John Zeibeq, source=Web Response