Pneumocystis Jirovecii Pneumonia (PJP) mistaken for COVID-19 in late stage undiagnosed: urgency of including HIV testing on admission
Simon Collins, HIV i-Base
On 1 July 2020, a letter to CID reported a case of missed diagnosis of HIV-related Pneumocystis Jirovecii Pneumonia in a person hospitalised with COVID-19. 
This case was a 52 year old gay man with a fever of 40°C, cough and shortness of breath who was hospitalised at Saarland University Medical Centre, Germany, and positively diagnosed with SARS-CoV-2 and bacterial infections that were treated with a broad antibiotic regimen containing meropenem and linezolid.
However, symptoms continued, leading to admission to ICU and ventilation. Differential cytology included a CD4 count of 12 cells/mm3, CD4% 2 and CD4:CD8 ratio of 0.08 then led to testing for HIV, which was positive with viral load of 360,000 copies/mL. Further details of diagnosis and management are included in the letter.
Oral ART was started immediately with twice-daily darunavir/ritonavir plus TDF/FTC. Trimethoprim-sulfamethoxazole was added to antibiotics and on the basis of CMV coinfection (170,000 U/mL blood), ganciclovir (5 mg/kg) was also added.
The patient recovered well, was able to discontinue ventilation and was later discharged from hospital.
The paper highlights the risk of COVID-19 masking symptoms of HIV infection but also that ART was safely started in a patient on ICU and that in this case the extremely low CD4 count did not result in IRIS.
This case further highlights the importance of including routine HIV testing in hospitalised cases of COVID-19. This should not just be based on risk factors for HIV, for example, because the case described above was a gay man.
Several other COVID-19 cohorts have also reported previously undiagnosed HIV, and even if this is at a higher CD4 count, it will enable referral to local HIV services.
Although these cases include very low CD4 counts and the late-stage HIV is important, COVID-19 might also directly contribute to worse absolute results. In this case, it is unclear why ganciclovir was included given the potential toxicity, and whether this was used to directly treat CMV or was being used as prophylaxis due to the low CD4 count.
On 7 April 2020, a letter to the BMJ raised an early concern for HIV/COVID-19 coinfection in HIV positive people in the UK who are undiagnosed or not on ART. This was also to ensure the best management of COVID-19 management in all HIV positive people, including to avoid interruption of HIV treatment. 
Unfortunately, an early missed UK case of HIV-related Pneumocystis Jirovecii Pneumonia being assumed to be COVID-19 has been anecdotally reported where, even after HIV was diagnosed, the patient died.
- Mang S et al. Pneumocystis Jirovecii Pneumonia and SARS-CoV-2 Co-Infection in newly diagnosed HIV-1 infection. Clinical Infectious Diseases, ciaa906, DOI: 10.1093/cid/ciaa906. (01 July 2020).
- Geretti AM, Collins S, Kelly S, Waters L. COVID-19 and HIV: Calling attention to the importance of ensuring HIV status and testing is included in the management of COVID-19. BMJ web blog. (7 April 2020).
- Why it is important to include HIV status and HIV testing in managing COVID-19. HTB (17 April 2020).
This article was first published on 7 July 2020.