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Servicio de Infectología
Hospital General “Dr. Fernando Quiroz Gutiérrez”, ISSSTE
CoordinadorMédico del turnoVespertino,
Ciudad de México
Dr. Luis Gerardo García Demuner has disclosed that he has received consulting fees from GlaxoSmithKline and fees for non-CME/CE services from Gilead Sciences and Janssen.
The continuity of care for persons living with HIV, including the distribution and acquisition of treatments, has been compromised during the COVID-19 pandemic in México. In the case below, I describe how one patient experienced delayed diagnosis of advanced HIV and opportunistic infections, exacerbated by reduced access to care.
Initial Presentation and Patient History
A 38-year-old man who has sex with men presented with increasingly loose stools in February 2020. He reported having more than 100 sexual partners since he became sexually active at 16 years of age. He does not smoke or use drugs but reported some alcohol use, including becoming drunk at least once every 3 months. He had a history of nonspecific chronic ulcerative colitis, for which he had taken mesalazine during flares since his diagnosis in 2012. His last flare was in 2015, and he has not followed up with gastroenterology since 2017. Since that time, he had not taken any medication, and at his February 2020 visit, he restarted mesalazine.
He presented to his social security clinic (ISSSTE) with persistent symptoms. The dose of mesalazine was increased, and he was referred back to gastroenterology. However, he was unable to get an appointment because the corresponding referral institution had been converted to a COVID-19–only hospital.
As his symptoms did not improve, he consulted a private doctor in April 2020. His erythrocyte sedimentation rate was 48 mm/hr. Stool examination revealed the presence of blood cells, mucus, and the parasite Cystoisospora belli. The patient experienced remarkable improvement of his symptoms after a 14-day course of trimethoprim-sulfamethoxazole (TMP-SMZ) to treat his cystoisosporiasis.
He presented with an 11-kg weight loss and generalized abdominal bloating, cramping, and rectal tenesmus. His doctor prescribed rectal mesalazine and ordered a colonoscopy. However, he did not get the colonoscopy because of the high cost at the private clinic, and the hospital was still not performing procedures unrelated to COVID-19.
He was experiencing bloody diarrhea and his generalized abdominal pain had reoccurred. The patient was considered for treatment with a biologic and tests were ordered per study protocol, including HIV, hepatitis B surface antigen, hepatitis B surface antibody, hepatitis C virus antibody, tuberculin skin tests, IgG and IgM for cytomegalovirus (CMV), and complete blood count. Given the expense of the studies, the patient decided to go back to his corresponding health service, where he finally received some of the recommended tests and was diagnosed with HIV. However, due to the COVID-19 pandemic, it was impossible to admit him to the hospital to treat his HIV and opportunistic infections. At the time, the national recommendations were that hospital care should be directed to patients with COVID-19, preventing patients with other diseases from being admitted.
The patient presented to our clinic with an 18-kg weight loss since the onset of symptoms, persistent diarrhea (up to 8 times/day with mucus and blood), and a new peripheral scotoma or blind spot of the right eye. He was sent to an infectious diseases (ID) specialist for assessment. As inpatient hospital facilities remained unavailable to non–COVID-19 patients and given the need to carry out further studies, he was cared for as an outpatient. During his first ID appointment, a comprehensive medical history was taken and a physical exam, complete blood work (CBC, creatinine, lipid test, etc), urinalysis, CD4+ cell count, HIV-1 RNA, ToRCH profile, comprehensive stool analysis, and thoracic and abdominal CT scans were conducted.
In a second visit 48 hours later, a colonoscopy with biopsies was finally performed. Appointments with gastroenterology, ophthalmology, and ID were made to review the results of the studies. At that point, he had elevated lactate dehydrogenase, aspartate aminotransferase, and alanine aminotransferase; a creatinine of 1 mg/dL; low high-density lipoprotein cholesterol; normal urinalysis; CD4+ cell count of 47 cells/mm3; and an HIV-1 RNA level of 317,776 copies/mL, and his stool exam was negative by Kinyoun stain. His CT scan showed mild hepatomegaly and generalized thickening of the colon wall. TMP-SMZ was prescribed for Pneumocystis jirovecii pneumonia prophylaxis. In ophthalmology, he was diagnosed with retinitis, probably secondary to CMV, and was started on valganciclovir. We explained to him his diagnoses, prognosis, and the impossibility of starting ART at that time due to the high risk of immune reconstitution inflammatory syndrome.
At his ID follow-up appointment 2 weeks later, the patient reported less abdominal pain, improved stool consistency, and no fever or chills. Colon ulcer biopsy results were compatible with CMV colitis, and the patient was diagnosed with disseminated CMV infection with affected colon and retina, and advanced stage (C3) HIV infection was confirmed. ART was begun following a discussion of risks and benefits with the patient.
November 2020 and Beyond
Currently, the patient is in the maintenance phase for CMV treatment, with an undetectable HIV-1 RNA and a CD4+ cell count of 97 cells/mm3. He is clinically stable with a 5-kg weight gain and no visual sequelae from the retinitis.
This case highlights multiple challenges faced in HIV care during the COVID-19 pandemic in México. His reduced access to care likely delayed his HIV diagnosis. Because he could not be admitted to the hospital, we had to perform multiple tests in an outpatient setting as quickly as possible while also protecting him from acquiring SARS-CoV-2 infection during his visits. Coordination among the different departments of the unit (ie, outpatient clinic, tomography, endoscopy, and laboratory) made it possible. Considering that hospitalization was not feasible to monitor him as he started treatment, we had to determine the best approach to reduce the risk of complications while maintaining therapeutic benefits.
Overall, the pandemic has presented us with an opportunity to re-evaluate our health system, to identify inefficiencies, and to make necessary modifications, including new test and study protocols that are better suited to outpatients, all while optimizing time and resources.
Join the Discussion!
The case above illustrates the difficult and lengthy path that our patients with HIV must navigate to obtain healthcare during the COVID-19 pandemic. How would this patient have been treated in your clinic? If you missed our live Webinars on this topic, you can watch my colleagues and me discuss these issues in these on-demand Webcasts.