First case of Coinfection with SARS-COV-2 and Cytomegaloviru
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This report describes first case of a 92-year-old woman who was admitted with fever and chills with laboratory evidence of coinfection with SARS-CoV-2 and cytomegalovirus. This merits investigation, as the literature suggests a link between SARS-CoV-2 and CMV infection/reactivation caused by the increasingly widespread use of anti-IL-6 and anti-IL-1 biological therapies in COVID-19.

A 92-year-old woman who was admitted to the University Hospital of Chieti with a 4-day history of fever and chills. She had a history of diabetes mellitus and arterial hypertension. Her family confirmed previous contact with patients positive for SARS-CoV-2. Clinical examination revealed the patient had bilateral crackles in both lungs. She was stable haemodynamically. Arterial blood gas (ABG) analysis, blood tests and a chest x-ray were carried out. The ABG results showed mild hypoxemic hypocapnic respiratory failure, the chest x-ray showed bilateral signs of interstitial pneumonia, and the blood tests showed lymphocytopenia, and an elevated erythrocyte sedimentation rate (42 mm), C-reactive protein (138 mg/l) and lactate dehydrogenase (471 U/l). Platelets were low (54 000/mm3) as was procalcitonin. These findings together with the history suggested the diagnosis of SARS-CoV-2 infection.

The patient was tested for SARS-CoV-2 with a positive result. Tests for influenza A and B, Chlamydia pneumoniae, Mycoplasma pneumoniae, Legionella pneumophila, Herpes simplex virus and Epstein-Barr virus were all negative for recent active infection. In light of the bilateral pneumonia and lymphocytopenia, the patient was also investigated for antibodies against cytomegalovirus (CMV): results showed high IgG (>180 U/ml) and IgM (38.7 U/ml) levels, indicating recent and likely active infection.

An infectious disease specialist was consulted and prescribed empirical therapy with lopinavir/ritonavir 200 mg twice a day plus hydroxychloroquine 200 mg twice a day. Bronchoscopy to obtain bronchoalveolar lavage for molecular diagnosis was not possible because of the patient’s unstable condition. Unfortunately, she died 6 days after admission due to severe respiratory failure in the clinical context of acute respiratory distress syndrome (ARDS).

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