29 February 2024 Volume :12 Issue :2

Study Findings have Serious Implications for Management of Immunocompromised Individuals with Persistent SARS-CoV-2

Study Findings have Serious Implications for Management of Immunocompromised Individuals with Persistent SARS-CoV-2
Severe HIV with persistent SARS-CoV-2.

Investigations into the case of a 70-year-old woman who presented with a cough and shortness of breath eventually led to a collaborative study which brought together scientists from South Africa and the United States with their findings published in the New England Journal of Medicine.

The findings have major implications for the management of immunocompromised individuals with persistent SARS-CoV-2 and demand further investigation into the situation.

This was heard by delegates at the 14th Annual Workshop on Advanced Clinical Care - AIDS in Durban, organised by Dr Henry Sunpath, and HOD: Infectious Diseases Unit at UKZN, Professor Mahomed-Yunus S Moosa.

KwaZulu-Natal (KZN) has the highest co-infection rates of Human Immunodeficiency Virus (HIV) and Tuberculosis (TB) in South Africa.

According to Dr Allison Castle of Massachusetts General Hospital (MGH), the 70-year-old patient was evaluated in a clinic in KZN because of a cough, shortness of breath, and malaise. The initial CD4 cell count obtained at the time of diagnosis was 29 cells per microliter, blood pressure 104/64 mm Hg, and her pulse was 87 beats per minute. The body mass index (the weight in kilograms divided by the square of the height in meters) was 16.9. On clinical examination, diffuse crackles were present in both lungs. Nucleic acid testing of a nasopharyngeal swab was positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Sputum Xpert MTB/Rif Ultra was also positive for Mycobacterium tuberculosis.

The patient also suffered headaches, mouth ulcers, chest pain, fatigue, night sweats and odynophagia. She did not smoke, drink alcohol, or use illicit drugs and she did not take any remedies from traditional healers. She had also not been vaccinated against COVID-19.

Dr Rajesh T Gandhi of MGH said: ‘Studies suggest that those with HIV infection have worse COVID outcomes, particularly if they have a low CD4 cell count or a high HIV Ribonucleic acid (RNA) level. Further, the possibility of persistent SARS-CoV-2 infection in persons with advanced HIV infection may lead to the evolution of SARS-CoV-2 viral mutations.’

Professor Tulio De Oliveira, who is the Director of the Centre for Epidemic Response and Innovation (CERI- Stellenbosch) and the KZN Research Innovation and Sequencing Platform (KRISP- UKZN) found that genomic data pointed to persistent SARS-CoV-2 infection with intrahost evolution in the case study, shedding light on intrahost viral dynamics and the potential for viral adaptation within immunocompromised individuals.

According to the infectious diseases specialist at UKZN, Dr Richard Lessells, since late 2020 multiple reports of persistent SARS-CoV-2 infection with intrahost evolution have been reported in immunocompromised individuals.

Said Lessells: ‘In South Africa, we have documented persistent infections with advanced HIV. Unfortunately, there is no evidence-based management guideline for persistent SARS-CoV-2 infections. We feel that the effective treatment of the underlying disease is an essential component of the management of persistent SARS-CoV-2 infection in immunocompromised individuals. This would include the introduction of antiretroviral therapy (ART) and HIV suppression.’

Dr Nithendra Manickchand of UKZN’s Department of Internal Medicine said: ‘There were no specific antiviral therapies for SARS-CoV-2 infections in South Africa at the time this patient presented. The goal was to suppress HIV replication and reconstitute her immune system to enable effective clearance of SARS-CoV-2.

‘Her ART regimen was changed to a dolutegravir-based regimen but the patient began to have severe headaches on the right side, ptosis of the right eye, and an inability to move her right eye laterally,’ said Manickchand. The woman presented to the clinic with these acute neurologic changes and was transferred to a hospital out of concern. Computed tomography (CT) of the head, performed after the administration of intravenous contrast material, revealed a mass in the cavernous sinus with occlusion of the right internal carotid artery. The mass was thought to be suggestive of aspergillosis. Whilst waiting for a biopsy of the intracranial mass, the patient died suddenly in hospital. The final diagnosis was advanced human immunodeficiency virus infection, persistent severe acute respiratory syndrome coronavirus 2 infection, and rhinocerebral aspergillus superinfection.’

Lessells said the presented case epitomised the multifaceted nature of advanced HIV disease and its attendant clinical complexities. ‘This case study indicates that the management of patients with advanced HIV and persistent SARS-CoV-2 requires further investigation. It is particularly concerning in the South African population where the uptake of the coronavirus vaccine has not been high, especially in the age groups with the highest HIV prevalence. We need to advocate for a more solid adult vaccination platform for people with comorbidities.’

Words: MaryAnn Francis

Image: Shutterstock


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