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

Patient: Male, 47-year-old Final Diagnosis: COVID pneumonia • hemophagocytic lymphohistiocytosis (HLH) • HIV infection • Kaposi sarcoma Symptoms: Fever • hepatomegaly • renal failure • respiratory distress • skin lesion Clinical Procedure: — Specialty: Infectious Diseases OBJECTIVE: Rare coexistence of disease or pathology BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) and Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) can trigger profound immune activation and systemic inflammation, leading to severe, often fatal, conditions. Simultaneously, HIV-infected patients, prone to immune dysregulation, face an increased risk of severe complications from SARS-CoV-2. The optimal timeline for initiating antiretroviral therapy (ART) in patients with severe SARS-CoV-2 and HIV co-infection, especially concerning the risk of HLH, remains uncertain. CASE REPORT: We detail the case of a 47-year-old male with previously undiagnosed HIV who, following ART initiation, developed HLH amid SARS-CoV-2 co-infection. The patient also had biopsy-proven Kaposi Sarcoma with immunoreactivity to Human Herpesvirus 8 (HHV-8), detectable peripheral blood Epstein Barr virus (EBV) DNA PCR and Cytomegalovirus (CMV) DNA PCR, and suspected Pneumocystis jirovecii pneumonia. We believe these conditions contributed to the development of HLH. This case represents a unique report of multiple herpesviruses reactivation, acquired HLH during COVID-19 in a patient with previously undiagnosed HIV. Despite receiving ART, steroids, and appropriate antimicrobial therapy, the patient’s condition did not improve. CONCLUSIONS: Further research is required to understand immune dysregulation, including HLH, in patients with HIV and SARSCoV-2 co-infection. The effects of ART initiation on treatment-naïve patients with potential concurrent opportunistic infections and/or herpesvirus reactivation warrant deeper examination to formulate clinical guidelines.